Provider Demographics
NPI:1821211525
Name:MACMILLAN, KASEY KATHLEEN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:KATHLEEN
Last Name:MACMILLAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 BOSTON ST
Mailing Address - Street 2:#423
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-4814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6040 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-1327
Practice Address - Country:US
Practice Address - Phone:901-573-1381
Practice Address - Fax:410-254-0619
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04542235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD04542OtherSTATE LICENSE