Provider Demographics
NPI:1205351251
Name:MULLINS, SUSAN TAYLOR (EDS)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:TAYLOR
Last Name:MULLINS
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 LAKE ST NE
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-7919
Mailing Address - Country:US
Mailing Address - Phone:276-328-8017
Mailing Address - Fax:276-328-6608
Practice Address - Street 1:628 LAKE ST NE
Practice Address - Street 2:
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293-7919
Practice Address - Country:US
Practice Address - Phone:276-328-8017
Practice Address - Fax:276-328-6608
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000076103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool