Provider Demographics
NPI:1851594402
Name:MULLEN, JOHNNY MARVIN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:MARVIN
Last Name:MULLEN
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 1:1080 TOMMYS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-8605
Mailing Address - Country:US
Mailing Address - Phone:336-922-2338
Mailing Address - Fax:336-786-7079
Practice Address - Street 1:1080 TOMMYS LAKE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-8605
Practice Address - Country:US
Practice Address - Phone:336-786-7079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0016301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical