Provider Demographics
NPI:1588661557
Name:MULLIN, MARY ANN (PH D)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:MULLIN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5808
Mailing Address - Country:US
Mailing Address - Phone:617-254-3800
Mailing Address - Fax:617-779-1262
Practice Address - Street 1:30 WARREN ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3602
Practice Address - Country:US
Practice Address - Phone:617-254-3800
Practice Address - Fax:617-779-1262
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4733103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50604Medicare ID - Type Unspecified