Healthcare Provider Details

I. General information

NPI: 1740441096
Provider Name (Legal Business Name): LIANE ELIZABETH MACMILLAN M.S. CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 TRENT RD
KRUM TX
76249-6690
US

IV. Provider business mailing address

1718 TRENT RD
KRUM TX
76249-6690
US

V. Phone/Fax

Practice location:
  • Phone: 505-362-1000
  • Fax: 940-482-8382
Mailing address:
  • Phone: 505-362-1000
  • Fax: 940-482-8382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number103121
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: