Provider Demographics
NPI:1215290929
Name:MCMILLIN, DEEDRA LEIGH (MED, BHRS)
Entity type:Individual
Prefix:MRS
First Name:DEEDRA
Middle Name:LEIGH
Last Name:MCMILLIN
Suffix:
Gender:F
Credentials:MED, BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-2351
Mailing Address - Country:US
Mailing Address - Phone:580-371-3799
Mailing Address - Fax:580-371-2056
Practice Address - Street 1:801 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2351
Practice Address - Country:US
Practice Address - Phone:580-371-3776
Practice Address - Fax:580-371-2056
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200226970AMedicaid