Provider Demographics
NPI:1871865634
Name:MULLEK, BETH A (LICSW)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:MULLEK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:A
Other - Last Name:PETRO-ROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:46 PAWTUCKET BLVD
Mailing Address - Street 2:#33
Mailing Address - City:TYNGSBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01879-1584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 MYRON ST
Practice Address - Street 2:SUITE A
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-1598
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0100
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1111161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical