Provider Demographics
NPI:1205068996
Name:MILLARD, RENEE EVELYN (FACT CERT #382)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:EVELYN
Last Name:MILLARD
Suffix:
Gender:F
Credentials:FACT CERT #382
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 CAMINO DEL RIO S
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3792
Mailing Address - Country:US
Mailing Address - Phone:619-294-8151
Mailing Address - Fax:
Practice Address - Street 1:2515 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3792
Practice Address - Country:US
Practice Address - Phone:619-294-8151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA588OtherAOD / CASE MANAGEMENT