Provider Demographics
NPI:1558892471
Name:MCMULLEN, KELLY (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 SE MORRISON ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-6307
Mailing Address - Country:US
Mailing Address - Phone:702-480-6028
Mailing Address - Fax:
Practice Address - Street 1:819 SE MORRISON ST
Practice Address - Street 2:SUITE 140
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-6307
Practice Address - Country:US
Practice Address - Phone:702-480-6028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20211405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional