Provider Demographics
NPI:1316395502
Name:MCMILLAN, KAITLIN ROSE (MA CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:KAITLIN
Middle Name:ROSE
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-4402
Mailing Address - Country:US
Mailing Address - Phone:212-289-4872
Mailing Address - Fax:
Practice Address - Street 1:25 E 104TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-4402
Practice Address - Country:US
Practice Address - Phone:212-289-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58025725235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist