Provider Demographics
NPI:1558059717
Name:MULLICAN, REBECCA (PHD, BCBA)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:MULLICAN
Suffix:
Gender:F
Credentials:PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6712 OLD CANTON RD STE 5
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1205
Mailing Address - Country:US
Mailing Address - Phone:769-218-9596
Mailing Address - Fax:
Practice Address - Street 1:6712 OLD CANTON RD STE 5
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1205
Practice Address - Country:US
Practice Address - Phone:769-218-9596
Practice Address - Fax:601-300-2903
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS190071103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst