Provider Demographics
NPI:1407900905
Name:MCMULLEN, SHELLY LYNN (BA QMHA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:LYNN
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:BA QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 SE 30TH AVE APT A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4900
Mailing Address - Country:US
Mailing Address - Phone:503-816-5449
Mailing Address - Fax:
Practice Address - Street 1:412 SW 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2329
Practice Address - Country:US
Practice Address - Phone:503-803-7624
Practice Address - Fax:503-944-2595
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator