Provider Demographics
NPI:1881878353
Name:MCMILLAN, MARY THERESA (LMFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:THERESA
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:LMFT
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 1236
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-1236
Mailing Address - Country:US
Mailing Address - Phone:707-972-3913
Mailing Address - Fax:707-279-2679
Practice Address - Street 1:6220 GOLD DUST DR
Practice Address - Street 2:
Practice Address - City:KELSEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95451-9214
Practice Address - Country:US
Practice Address - Phone:707-972-3913
Practice Address - Fax:707-279-2679
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38132106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist