Provider Demographics
NPI:1780802124
Name:MILLS, MICHAEL RAYMOND
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:MILLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 CATALINA PL
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3833 S STAPLES ST STE N206
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-5235
Practice Address - Country:US
Practice Address - Phone:361-884-7600
Practice Address - Fax:361-884-7677
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7366101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1772055-01Medicaid