Provider Demographics
NPI:1295837771
Name:BECKNELL, MILTON EDWARD (PHD)
Entity type:Individual
Prefix:DR
First Name:MILTON
Middle Name:EDWARD
Last Name:BECKNELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7244 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4207
Mailing Address - Country:US
Mailing Address - Phone:937-684-2035
Mailing Address - Fax:937-395-1311
Practice Address - Street 1:7244 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4207
Practice Address - Country:US
Practice Address - Phone:937-684-2035
Practice Address - Fax:937-395-1311
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5682103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2453394Medicaid
OHMIS586680000OtherGREEN SPRING (MAGELLAN)
OHMIS586680000OtherEMPIRE BC/BS
OH000000351504Medicare UPIN
OHMIS586680000OtherEMPIRE BC/BS
OHBECP 3021Medicare ID - Type Unspecified