Healthcare Provider Details

I. General information

NPI: 1992627053
Provider Name (Legal Business Name): CARLIE CATHERINE MACMILLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SOUTHLAKE BLVD STE 202
NORTH CHESTERFIELD VA
23236-3085
US

IV. Provider business mailing address

301 SOUTHLAKE BLVD STE 202
NORTH CHESTERFIELD VA
23236-3085
US

V. Phone/Fax

Practice location:
  • Phone: 804-621-1747
  • Fax:
Mailing address:
  • Phone: 804-621-1747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202012549
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: