Provider Demographics
NPI:1780642363
Name:MULLIS, ROBERT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:MULLIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 WEST END AVENUE
Mailing Address - Street 2:20R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-5512
Mailing Address - Country:US
Mailing Address - Phone:212-238-7614
Mailing Address - Fax:212-238-7009
Practice Address - Street 1:227 MADISON STREET
Practice Address - Street 2:ROOM 391
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002
Practice Address - Country:US
Practice Address - Phone:212-238-7393
Practice Address - Fax:212-238-7399
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0475131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400015427Medicare PIN
Q18125Medicare UPIN
N636M1Medicare ID - Type Unspecified