Provider Demographics
NPI:1942815766
Name:MCMILLAN, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MCMILLAN
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 1:145 MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02896-7133
Mailing Address - Country:US
Mailing Address - Phone:401-368-8110
Mailing Address - Fax:
Practice Address - Street 1:193 OAK ST STE 1
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464-1453
Practice Address - Country:US
Practice Address - Phone:617-658-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician