Provider Demographics
NPI:1558486647
Name:MULLINS, WENDY ANN
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:ANN
Last Name:MULLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4447 S CANYON RD
Mailing Address - Street 2:SUITE # 5
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-1807
Mailing Address - Country:US
Mailing Address - Phone:605-412-4443
Mailing Address - Fax:605-385-0035
Practice Address - Street 1:4447 S CANYON RD
Practice Address - Street 2:SUITE # 5
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-1807
Practice Address - Country:US
Practice Address - Phone:605-412-4443
Practice Address - Fax:605-385-0035
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD535103TC0700X
COPSY.0003913103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47689321Medicaid
SD6553550Medicaid