Provider Demographics
NPI:1053064295
Name:MULLIN, MADISON SHAE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:SHAE
Last Name:MULLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4364 MILFORD PL
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-1674
Mailing Address - Country:US
Mailing Address - Phone:502-370-7532
Mailing Address - Fax:
Practice Address - Street 1:1093 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30344-6740
Practice Address - Country:US
Practice Address - Phone:404-768-2218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW010296104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker