Provider Demographics
NPI:1750010914
Name:FOXWORTH, MILANA NICHELLE
Entity Type:Individual
Prefix:
First Name:MILANA
Middle Name:NICHELLE
Last Name:FOXWORTH
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 1:4230 OAK LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5520
Mailing Address - Country:US
Mailing Address - Phone:618-580-2810
Mailing Address - Fax:
Practice Address - Street 1:4230 OAK LN
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5520
Practice Address - Country:US
Practice Address - Phone:618-580-2810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-05
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0232021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical