Provider Demographics
NPI:1184209181
Name:MULLEN, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:MULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 TUOLUMNE ST # 2500
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-5700
Mailing Address - Country:US
Mailing Address - Phone:707-553-5525
Mailing Address - Fax:
Practice Address - Street 1:355 TUOLUMNE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5700
Practice Address - Country:US
Practice Address - Phone:707-553-5331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician