Provider Demographics
NPI:1043332349
Name:MULL, LISA JEANNE (PSYD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JEANNE
Last Name:MULL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 PINION DR
Mailing Address - Street 2:
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840-2502
Mailing Address - Country:US
Mailing Address - Phone:719-333-5154
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3317103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical