Provider Demographics
NPI:1366574287
Name:MILNE, MAVIS (PHD)
Entity type:Individual
Prefix:
First Name:MAVIS
Middle Name:
Last Name:MILNE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-1524
Mailing Address - Country:US
Mailing Address - Phone:301-367-3241
Mailing Address - Fax:
Practice Address - Street 1:1430 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1524
Practice Address - Country:US
Practice Address - Phone:301-367-3241
Practice Address - Fax:301-565-2668
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3873103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG01750C01Medicare ID - Type Unspecified