Provider Demographics
NPI:1053640235
Name:MULLEN-MAGBALON, SHANNON D (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:D
Last Name:MULLEN-MAGBALON
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:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-0378
Mailing Address - Country:US
Mailing Address - Phone:229-200-3157
Mailing Address - Fax:
Practice Address - Street 1:229 REMINGTON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5599
Practice Address - Country:US
Practice Address - Phone:229-200-3157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003406103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling