Healthcare Provider Details

I. General information

NPI: 1912705070
Provider Name (Legal Business Name): MARK FERNANDES MCMILLAN M.SC., CPC, CLC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

300 W PENSACOLA ST FL 3
TALLAHASSEE FL
32301-1618
US

IV. Provider business mailing address

659 DUNN ST
TALLAHASSEE FL
32304-2458
US

V. Phone/Fax

Practice location:
  • Phone: 877-572-3399
  • Fax: 877-572-3399
Mailing address:
  • Phone: 877-572-3399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: