Provider Demographics
NPI:1659437432
Name:MCMULLEN, MIA MCMULLEN (SLP)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:MCMULLEN
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3318 ROYAL SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-7107
Mailing Address - Country:US
Mailing Address - Phone:404-248-0415
Mailing Address - Fax:404-248-0422
Practice Address - Street 1:3760 LAVISTA ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:404-248-0415
Practice Address - Fax:404-248-0422
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00899346AMedicaid