Provider Demographics
NPI:1124000351
Name:MULRENIN, KATHLEEN (PHD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MULRENIN
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 1:61 MAIN ST STE 64
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-8300
Mailing Address - Country:US
Mailing Address - Phone:207-470-0571
Mailing Address - Fax:877-320-4344
Practice Address - Street 1:61 MAIN ST STE 64
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-8300
Practice Address - Country:US
Practice Address - Phone:207-470-0571
Practice Address - Fax:877-320-4344
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1035103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME999020301Medicaid
MM9066Medicare ID - Type Unspecified
S23047Medicare UPIN