Provider Demographics
NPI:1831486216
Name:MCMILLIN, BONNIE SUE (LP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:SUE
Last Name:MCMILLIN
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 PORTLAND AVE
Mailing Address - Street 2:3
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2499
Mailing Address - Country:US
Mailing Address - Phone:507-202-5698
Mailing Address - Fax:
Practice Address - Street 1:457 PORTLAND AVE
Practice Address - Street 2:3
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2499
Practice Address - Country:US
Practice Address - Phone:507-202-5698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5384103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical