Provider Demographics
NPI:1689714164
Name:MCMULLEN, JUANITA THERESA (SP)
Entity Type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:THERESA
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:SP
Other - Prefix:
Other - First Name:JUANITA
Other - Middle Name:THERESA
Other - Last Name:AUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:885 HOWLAND WILSON RD NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2115
Mailing Address - Country:US
Mailing Address - Phone:330-856-2107
Mailing Address - Fax:330-856-2107
Practice Address - Street 1:885 HOWLAND WILSON RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2115
Practice Address - Country:US
Practice Address - Phone:330-856-2107
Practice Address - Fax:330-856-2107
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-2820235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000217945OtherANTHEM
OH8674500Medicaid