Provider Demographics
NPI:1972932424
Name:MCMILLAN, T.STACEY (LPT, LMFT, PHD)
Entity Type:Individual
Prefix:DR
First Name:T.STACEY
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:LPT, LMFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-0728
Mailing Address - Country:US
Mailing Address - Phone:732-497-0666
Mailing Address - Fax:732-518-5032
Practice Address - Street 1:43 W FRONT ST STE B
Practice Address - Street 2:
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-3601
Practice Address - Country:US
Practice Address - Phone:732-407-0006
Practice Address - Fax:732-518-5032
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTM714709D103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist