Provider Demographics
NPI:1932688595
Name:MACMILLAN, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:MACMILLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:EDGAR
Mailing Address - State:WI
Mailing Address - Zip Code:54426-9266
Mailing Address - Country:US
Mailing Address - Phone:715-297-3752
Mailing Address - Fax:
Practice Address - Street 1:500 N 3RD ST STE 220
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-4857
Practice Address - Country:US
Practice Address - Phone:715-204-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI3937103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health