Provider Demographics
NPI:1942777362
Name:MULLEN, GRACE (PSYCHOLOGY INTERN)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MULLEN
Suffix:
Gender:F
Credentials:PSYCHOLOGY INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 3RD ST ENTRANCE HOLLY LANE
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1217
Mailing Address - Country:US
Mailing Address - Phone:440-323-5707
Mailing Address - Fax:
Practice Address - Street 1:312 3RD ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5618
Practice Address - Country:US
Practice Address - Phone:440-323-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X, 172V00000X
251S00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No251S00000XAgenciesCommunity/Behavioral Health