Provider Demographics
NPI:1760106959
Name:MULLIN, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MULLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4702 N 133RD PLZ APT 111
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-1010
Mailing Address - Country:US
Mailing Address - Phone:402-630-2016
Mailing Address - Fax:
Practice Address - Street 1:17712 JOSEPHINE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68136-2023
Practice Address - Country:US
Practice Address - Phone:402-366-3472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13655101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health