MEDICARE: REGINA M MCMILLIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1588170534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINA M MCMILLIN

Provider Business Mailing Address
First Line	:	9315 SANDRA GRACE RD
Second Line	:
City	:	SOUTHPORT
State	:	FL
Zip	:	32409-1834
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9315 SANDRA GRACE RD
Second Line	:
City	:	SOUTHPORT
State	:	FL
Zip	:	32409-1834
Country	:	US
Telephone Number	:	850-319-4596
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2017
Last Update Date	:	12/28/2017

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Directions to “ REGINA M MCMILLIN ” Practice Location

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