Provider Demographics
NPI:1750896072
Name:MCMILLAN, TARIK MALACHI (MSED)
Entity type:Individual
Prefix:
First Name:TARIK
Middle Name:MALACHI
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:MSED
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 1833
Mailing Address - Street 2:
Mailing Address - City:FREDERIKSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00841-1833
Mailing Address - Country:US
Mailing Address - Phone:340-332-2717
Mailing Address - Fax:
Practice Address - Street 1:40 EG LAGRANGE
Practice Address - Street 2:
Practice Address - City:FREDERIKSTED
Practice Address - State:VI
Practice Address - Zip Code:00840
Practice Address - Country:US
Practice Address - Phone:340-332-2717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
VI2-43354-1L101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI2-43354OtherDEPARTMENT OF LICENSING AND CONSUMER AFFAIRS