Healthcare Provider Details

I. General information

NPI: 1609566553
Provider Name (Legal Business Name): BREANNA MAUREEN MCMILLAN CONDE MS, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANNA MAUREEN MCMILLAN MS, RMHCI

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 PROSPERITY LAKE DR # 101
ST AUGUSTINE FL
32092-5045
US

IV. Provider business mailing address

495 PROSPERITY LAKE DR # 101
ST AUGUSTINE FL
32092-5045
US

V. Phone/Fax

Practice location:
  • Phone: 904-370-3420
  • Fax:
Mailing address:
  • Phone: 718-715-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH23990
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH25818
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: