Provider Demographics
NPI:1255484077
Name:MULLIS, LYNNE A (LCSW)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:A
Last Name:MULLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LYNNE
Other - Middle Name:A
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 HIGH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464
Mailing Address - Country:US
Mailing Address - Phone:484-941-0500
Mailing Address - Fax:484-941-0515
Practice Address - Street 1:361 HIGH ST
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464
Practice Address - Country:US
Practice Address - Phone:610-326-9250
Practice Address - Fax:610-327-8726
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0121841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q56457Medicare UPIN
651538FRKMedicare ID - Type Unspecified