Provider Demographics
NPI:1285006817
Name:MCMULLEN, SAMUEL (DPT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MCMULLEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5000
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12504-5000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 S CENTER ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3121
Practice Address - Country:US
Practice Address - Phone:860-621-5054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002102-012255A2300X
CT12235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer