Provider Demographics
NPI:1700850823
Name:MULLEN, JOHN THOMAS (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:MULLEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 E 26TH ST STE 503
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4515
Mailing Address - Country:US
Mailing Address - Phone:612-863-5100
Mailing Address - Fax:612-863-5109
Practice Address - Street 1:913 E 26TH ST STE 503
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4515
Practice Address - Country:US
Practice Address - Phone:612-863-5100
Practice Address - Fax:612-863-5109
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4239103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN604909500Medicaid