MEDICARE: MS. JOAN MARIE MACMILLAN MFT

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	101YM0800X	Mental Health Counselor	MFC17450	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MHN ID 067243	OTHER	CA	PROVIDER MHN ID #

General Provider Information

NPI Number	:	1629088067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JOAN MARIE MACMILLAN MFT

Provider Business Mailing Address
First Line	:	7803 MADISON AVE STE 702
Second Line	:
City	:	CITRUS HTS
State	:	CA
Zip	:	95610-7695
Country	:	US
Telephone Number	:	916-967-0991
Fax Number	:	916-967-4080

Provider Business Practice Location Address
First Line	:	7803 MADISON AVE STE 702
Second Line	:
City	:	CITRUS HTS
State	:	CA
Zip	:	95610-7695
Country	:	US
Telephone Number	:	916-967-0991
Fax Number	:	916-967-4080

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	07/08/2007

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