Provider Demographics
NPI:1447815790
Name:MILLETT, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MILLETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 LINCOLN AVE # GN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1934
Mailing Address - Country:US
Mailing Address - Phone:630-995-5486
Mailing Address - Fax:
Practice Address - Street 1:111 S GRANT ST
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-4050
Practice Address - Country:US
Practice Address - Phone:630-563-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012199101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional