Basic Information
Provider Information | |||||||||
NPI: | 1700979192 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCMILLAN | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3803 MARION AVE | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 38111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9013245448 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3810 WINCHESTER RD | ||||||||
Address2: | SOUTHEAST MENTAL HEALTH CENTER | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381189007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9013691420 | ||||||||
FaxNumber: | 9013691433 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 344 | TN | X |   | Behavioral Health & Social Service Providers | Counselor |   | 101YA0400X | 344 | TN | X |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 344 | TN | X |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 344 | TN | X |   | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC0700X | 870 | TN | X |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 106H00000X | 128 | TN | X |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.