Provider Demographics
NPI:1174640742
Name:MULLEN, SHANE J (LCP)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:J
Last Name:MULLEN
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-6127
Mailing Address - Country:US
Mailing Address - Phone:620-341-0865
Mailing Address - Fax:
Practice Address - Street 1:2950 SW WOODSIDE DR
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-5326
Practice Address - Country:US
Practice Address - Phone:785-272-5134
Practice Address - Fax:785-272-4370
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS052103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200434290BMedicaid