Provider Demographics
NPI:1558909077
Name:MILLARD, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:MILLARD
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 1:4385 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-5509
Mailing Address - Country:US
Mailing Address - Phone:443-878-6110
Mailing Address - Fax:
Practice Address - Street 1:10015 OLD COLUMBIA RD STE B215
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1865
Practice Address - Country:US
Practice Address - Phone:443-766-9422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician