Provider Demographics
NPI:1548744071
Name:MCMULLEN, STACEY (MSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:MSW
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 23625
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-3625
Mailing Address - Country:US
Mailing Address - Phone:505-660-8559
Mailing Address - Fax:
Practice Address - Street 1:1501 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3521
Practice Address - Country:US
Practice Address - Phone:505-216-7325
Practice Address - Fax:505-395-7406
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-10748101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional