Provider Demographics
NPI:1306361340
Name:MCMILLAN, MYRNA JARVIS (AMFT)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:JARVIS
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-1827
Mailing Address - Country:US
Mailing Address - Phone:801-427-3052
Mailing Address - Fax:
Practice Address - Street 1:5667 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5433
Practice Address - Country:US
Practice Address - Phone:801-979-1351
Practice Address - Fax:801-979-1351
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT101Y00000XMedicaid