Provider Demographics
NPI:1356405633
Name:MCMILLAN, CANDACE KAY (PSYD)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:KAY
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 OLD CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1409
Mailing Address - Country:US
Mailing Address - Phone:708-448-4115
Mailing Address - Fax:708-448-4115
Practice Address - Street 1:11952 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1167
Practice Address - Country:US
Practice Address - Phone:773-519-4103
Practice Address - Fax:708-361-5222
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1629342103TS0200X
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical