Provider Demographics
NPI:1184098865
Name:MULL, MARILYN (LCSW)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:MULL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2672 NW SKYLEE DR APT 3
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1989
Mailing Address - Country:US
Mailing Address - Phone:541-378-4590
Mailing Address - Fax:
Practice Address - Street 1:2672 NW SKYLEE DR APT 3
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1989
Practice Address - Country:US
Practice Address - Phone:541-378-4590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1242261QM0850X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1295901809OtherNPPES