Provider Demographics
NPI:1881619534
Name:MCMILLAN, MAREN HART (PSYD LP)
Entity type:Individual
Prefix:
First Name:MAREN
Middle Name:HART
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 UNIVERSITY W AVE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1854
Mailing Address - Country:US
Mailing Address - Phone:651-644-4100
Mailing Address - Fax:651-644-4885
Practice Address - Street 1:2324 UNIVERSITY W AVE 120
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1854
Practice Address - Country:US
Practice Address - Phone:651-644-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4624103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN111026800Medicaid
680002061Medicare ID - Type Unspecified