Provider Demographics
NPI:1669011771
Name:MCMILLEN, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:MCMILLEN
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 1:5796 FARM FIELD DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-9773
Mailing Address - Country:US
Mailing Address - Phone:513-320-6226
Mailing Address - Fax:
Practice Address - Street 1:820 E CENTER ST
Practice Address - Street 2:
Practice Address - City:BLANCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45107-1310
Practice Address - Country:US
Practice Address - Phone:937-783-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5549225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant