Provider Demographics
NPI:1407615685
Name:MCMILLAN, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:MCMILLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1644 US HIGHWAY 82 E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-9347
Mailing Address - Country:US
Mailing Address - Phone:229-396-5596
Mailing Address - Fax:
Practice Address - Street 1:111 COFFEE AVE N
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-0341
Practice Address - Country:US
Practice Address - Phone:229-396-5596
Practice Address - Fax:229-396-4971
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-24-71840103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst