Provider Demographics
NPI:1649924754
Name:MCMILLAN FORD, REVA (LCSW)
Entity type:Individual
Prefix:
First Name:REVA
Middle Name:
Last Name:MCMILLAN FORD
Suffix:
Gender:F
Credentials:LCSW
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 801206
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75380-1206
Mailing Address - Country:US
Mailing Address - Phone:318-381-9554
Mailing Address - Fax:
Practice Address - Street 1:15190 PRESTONWOOD BLVD APT 3131023
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-4730
Practice Address - Country:US
Practice Address - Phone:318-381-9554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX599881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX59988OtherTBSWE