Provider Demographics
NPI:1710691134
Name:MULLIN, LISA MICHELE (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELE
Last Name:MULLIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 GLENVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-3400
Mailing Address - Country:US
Mailing Address - Phone:573-380-9677
Mailing Address - Fax:
Practice Address - Street 1:3417 GLENVIEW DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-3400
Practice Address - Country:US
Practice Address - Phone:573-380-9677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018001452101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health