Provider Demographics
NPI:1376659342
Name:MULLAN, ROBERTA JACQUELINE (LADC)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:JACQUELINE
Last Name:MULLAN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 CRESSEY RD
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04259-6804
Mailing Address - Country:US
Mailing Address - Phone:207-933-4092
Mailing Address - Fax:
Practice Address - Street 1:256 CRESSEY RD
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04259-6804
Practice Address - Country:US
Practice Address - Phone:207-933-4092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC1420101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)