Healthcare Provider Details

I. General information

NPI: 1285400556
Provider Name (Legal Business Name): CHERYL ANNE MCMILLEN PEER SUPPORT SPECIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2023
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 3RD ST
LINCOLN CA
95648-1562
US

IV. Provider business mailing address

1530 3RD ST
LINCOLN CA
95648-1562
US

V. Phone/Fax

Practice location:
  • Phone: 916-532-9771
  • Fax:
Mailing address:
  • Phone: 916-532-9771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1552270324
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-ERJOAP
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: