Provider Demographics
NPI:1417508649
Name:MCMILLAN, BRYANT KEITH
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:KEITH
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 WORTHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01109-4027
Mailing Address - Country:US
Mailing Address - Phone:413-747-5384
Mailing Address - Fax:413-382-7170
Practice Address - Street 1:20 WILBRAHAM AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-3337
Practice Address - Country:US
Practice Address - Phone:413-747-5384
Practice Address - Fax:413-382-7170
Is Sole Proprietor?:No
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)