Provider Demographics
NPI:1669033817
Name:NEGUSSE, MILENA
Entity Type:Individual
Prefix:
First Name:MILENA
Middle Name:
Last Name:NEGUSSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7522 OVERDALE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2832
Mailing Address - Country:US
Mailing Address - Phone:214-415-3007
Mailing Address - Fax:
Practice Address - Street 1:4821 MERLOT AVE UNIT 210
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7386
Practice Address - Country:US
Practice Address - Phone:877-264-6747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2023-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-21-51900103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst