Provider Demographics
NPI:1922285196
Name:MARIA D. MILILLO, PH.D. PA
Entity Type:Organization
Organization Name:MARIA D. MILILLO, PH.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-879-0414
Mailing Address - Street 1:8183 JULIANNE TER
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55427-3928
Mailing Address - Country:US
Mailing Address - Phone:612-879-0414
Mailing Address - Fax:
Practice Address - Street 1:15 GROVELAND TER
Practice Address - Street 2:201
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-1154
Practice Address - Country:US
Practice Address - Phone:612-879-0414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0579103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN942747300Medicaid
MN57648MIOtherBLUE CROSS BLUE SHIELD
MN680000562Medicare PIN