Healthcare Provider Details

I. General information

NPI: 1174853386
Provider Name (Legal Business Name): CARMEN MARIE MACMILLAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2010
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 CLUB RD STE 120
EUGENE OR
97401-2439
US

IV. Provider business mailing address

66 CLUB RD STE 160
EUGENE OR
97401-2439
US

V. Phone/Fax

Practice location:
  • Phone: 541-393-5983
  • Fax: 541-393-5984
Mailing address:
  • Phone: 541-345-1722
  • Fax: 541-485-7049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC5822
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier15091907
Identifier TypeOTHER
Identifier State
Identifier IssuerCAQH ID
# 2
Identifier500661183
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: