Provider Demographics
NPI:1578549176
Name:MULLEN, TIMOTHY M (OTR)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:MULLEN
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6406
Mailing Address - Country:US
Mailing Address - Phone:616-459-7101
Mailing Address - Fax:616-954-6483
Practice Address - Street 1:1111 LEFFINGWELL AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6406
Practice Address - Country:US
Practice Address - Phone:616-459-7101
Practice Address - Fax:616-954-6483
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002530225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP04770001Medicare ID - Type UnspecifiedOCCUPATIONAL THERAPIST