Provider Demographics
NPI:1902256662
Name:MILLS, DEIDEDRE LYNN
Entity Type:Individual
Prefix:
First Name:DEIDEDRE
Middle Name:LYNN
Last Name:MILLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 ALTON WAY
Mailing Address - Street 2:APT 2113
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-6144
Mailing Address - Country:US
Mailing Address - Phone:720-327-5189
Mailing Address - Fax:
Practice Address - Street 1:550 ALTON WAY
Practice Address - Street 2:APT 2113
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230-6144
Practice Address - Country:US
Practice Address - Phone:720-327-5189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO390200000101YS0200X
CO39390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO39020000Medicare PIN
CO39000000XMedicare PIN