Provider Demographics
NPI:1437653375
Name:MCMILLAN, ADEJARE ABISOGUN
Entity Type:Individual
Prefix:
First Name:ADEJARE
Middle Name:ABISOGUN
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 1:2818 MAYO ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-5646
Mailing Address - Country:US
Mailing Address - Phone:954-993-6055
Mailing Address - Fax:
Practice Address - Street 1:2818 MAYO ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-5646
Practice Address - Country:US
Practice Address - Phone:954-993-6055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH16474101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health