Provider Demographics
NPI:1093364580
Name:MULLEN, CHARLES DUSTIN
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DUSTIN
Last Name:MULLEN
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 1:201 MEADOW MNR
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:851 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18519-1759
Practice Address - Country:US
Practice Address - Phone:570-489-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health