Provider Demographics
NPI:1255561932
Name:MCMILLAN, TINA GALE (MFT)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:GALE
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1748 NOVATO BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-7855
Mailing Address - Country:US
Mailing Address - Phone:415-898-6455
Mailing Address - Fax:415-983-2513
Practice Address - Street 1:1748 NOVATO BLVD STE 210
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-7855
Practice Address - Country:US
Practice Address - Phone:415-898-6455
Practice Address - Fax:415-983-2513
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25036106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist