Provider Demographics
NPI:1235583063
Name:MULLIGAN, MICHAEL TREW (AMFT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TREW
Last Name:MULLIGAN
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5017 ROSCREA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-1544
Mailing Address - Country:US
Mailing Address - Phone:909-615-9641
Mailing Address - Fax:
Practice Address - Street 1:5348 UNIVERSITY AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-8025
Practice Address - Country:US
Practice Address - Phone:619-229-2999
Practice Address - Fax:619-229-2997
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA102517106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program