Basic Information
| Provider Information | |||||||||
| NPI: | 1285952416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACMILLAN | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | RONALD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 INVERNESS DR W | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801125095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037799676 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 61 W DAVIES AVE N | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801205252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037799676 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2010 | ||||||||
| LastUpdateDate: | 10/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5630 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 16082842 | 05 | CO | MEDICAID |