Provider Demographics
NPI:1447617113
Name:BAIZE MILLSAPS, MAGAN DANIELLE (LPCC, LCADC)
Entity Type:Individual
Prefix:
First Name:MAGAN
Middle Name:DANIELLE
Last Name:BAIZE MILLSAPS
Suffix:
Gender:F
Credentials:LPCC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-2956
Mailing Address - Country:US
Mailing Address - Phone:270-689-6547
Mailing Address - Fax:270-689-6689
Practice Address - Street 1:1100 WALNUT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301
Practice Address - Country:US
Practice Address - Phone:270-689-6547
Practice Address - Fax:270-689-6689
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY165042101Y00000X
KY164978101YA0400X, 101YP2500X
KY241828101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100412490Medicaid