Provider Demographics
NPI:1477642239
Name:MCMILLAN, MICHAEL D (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43800 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:313-343-3481
Mailing Address - Fax:313-343-7937
Practice Address - Street 1:22201 MOROSS RD
Practice Address - Street 2:270
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2169
Practice Address - Country:US
Practice Address - Phone:313-343-3481
Practice Address - Fax:313-343-7937
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002599103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H208910OtherBLUE CROSS GROUP
MI0H260650OtherBLUE CROSS