Healthcare Provider Details

I. General information

NPI: 1477642239
Provider Name (Legal Business Name): MICHAEL D MCMILLAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22201 MOROSS RD 270
DETROIT MI
48236-2169
US

IV. Provider business mailing address

43800 GARFIELD RD
CLINTON TWP MI
48038-1136
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-3481
  • Fax: 313-343-7937
Mailing address:
  • Phone: 313-343-3481
  • Fax: 313-343-7937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301002599
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: