Provider Demographics
NPI:1609566553
Name:MCMILLAN, BREANNA MAUREEN (MS, RMHCI)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:MAUREEN
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:MS, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 CALLISTO WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-1229
Mailing Address - Country:US
Mailing Address - Phone:718-715-2400
Mailing Address - Fax:
Practice Address - Street 1:495 PROSPERITY LAKE DR # 101
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5045
Practice Address - Country:US
Practice Address - Phone:904-370-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH23990101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health