Provider Demographics
NPI:1730274630
Name:MCMILLEN, KELLEY (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MCMILLEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SEA BREEZE ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-6254
Mailing Address - Country:US
Mailing Address - Phone:505-315-7557
Mailing Address - Fax:505-830-0106
Practice Address - Street 1:2819 RICHMOND DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1918
Practice Address - Country:US
Practice Address - Phone:505-883-3787
Practice Address - Fax:505-830-0106
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2656235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65307577Medicaid
NM10026769OtherLOVELACE HEALTH PLAN
NMQMYPR0072406OtherMOLINA HEALTH CARE