Provider Demographics
NPI:1083731301
Name:MCMULLEN, MICHAEL JOHN (CAC-M)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:MCMULLEN
Suffix:
Gender:M
Credentials:CAC-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6765 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-1827
Mailing Address - Country:US
Mailing Address - Phone:313-386-9040
Mailing Address - Fax:
Practice Address - Street 1:13220 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3610
Practice Address - Country:US
Practice Address - Phone:313-852-1637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-03872101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1740313238OtherCHRIATIAN GUIDANCE CENTER
MI3022440Medicaid