Provider Demographics
NPI:1477330777
Name:MCMILLIAN, LADARIUS
Entity Type:Individual
Prefix:
First Name:LADARIUS
Middle Name:
Last Name:MCMILLIAN
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 1:526 COTTONBROOK CV
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-4708
Mailing Address - Country:US
Mailing Address - Phone:662-275-0750
Mailing Address - Fax:
Practice Address - Street 1:526 COTTONBROOK CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4708
Practice Address - Country:US
Practice Address - Phone:662-275-0750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA6525225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant