Provider Demographics
NPI:1356497069
Name:MULLEN, GAVIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:
Last Name:MULLEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 SKOKIE BLVD
Mailing Address - Street 2:215
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-4013
Mailing Address - Country:US
Mailing Address - Phone:847-682-4514
Mailing Address - Fax:847-291-0576
Practice Address - Street 1:910 SKOKIE BLVD
Practice Address - Street 2:215
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-4013
Practice Address - Country:US
Practice Address - Phone:847-682-4514
Practice Address - Fax:847-291-0576
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004627103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical