Healthcare Provider Details

I. General information

NPI: 1417570730
Provider Name (Legal Business Name): MADELINE MACMILLIN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2070 BUSINESS CENTER DR
IRVINE CA
92612-1127
US

IV. Provider business mailing address

2070 BUSINESS CENTER DR
IRVINE CA
92612-1127
US

V. Phone/Fax

Practice location:
  • Phone: 949-519-0088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: