Provider Demographics
NPI:1609270321
Name:MCMILLAN, BLAIRE (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:BLAIRE
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1679 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:OSYKA
Mailing Address - State:MS
Mailing Address - Zip Code:39657-8197
Mailing Address - Country:US
Mailing Address - Phone:985-517-1398
Mailing Address - Fax:
Practice Address - Street 1:1679 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:OSYKA
Practice Address - State:MS
Practice Address - Zip Code:39657-8197
Practice Address - Country:US
Practice Address - Phone:985-517-1398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7246235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist