Provider Demographics
NPI:1306087127
Name:MILLS, THERON (MS / LPC)
Entity type:Individual
Prefix:MS
First Name:THERON
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:MS / LPC
Other - Prefix:
Other - First Name:THERON
Other - Middle Name:
Other - Last Name:MILLS-JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3073 S. CHASE AVE.
Mailing Address - Street 2:SUITE 326
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207
Mailing Address - Country:US
Mailing Address - Phone:414-881-8288
Mailing Address - Fax:414-289-1175
Practice Address - Street 1:3073 S. CHASE AVE.
Practice Address - Street 2:SUITE 326
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207
Practice Address - Country:US
Practice Address - Phone:414-881-8288
Practice Address - Fax:414-289-1175
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2396-125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI396-47-600Medicaid