Provider Demographics
NPI:1356893705
Name:MCMILLAN, DEASIA MONIQUE (COTA)
Entity type:Individual
Prefix:
First Name:DEASIA
Middle Name:MONIQUE
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 HIGHOAK DR NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-4932
Mailing Address - Country:US
Mailing Address - Phone:520-979-6425
Mailing Address - Fax:
Practice Address - Street 1:1865 BOLD SPRINGS RD NW
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30656-4605
Practice Address - Country:US
Practice Address - Phone:770-267-8677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4333224Z00000X
GAOTA002107224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant