Provider Demographics
NPI:1295251056
Name:MULLANE, MICHAEL PATRICK (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:MULLANE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 TOWER ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1426
Mailing Address - Country:US
Mailing Address - Phone:617-591-4245
Mailing Address - Fax:
Practice Address - Street 1:33 TOWER ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1426
Practice Address - Country:US
Practice Address - Phone:617-591-4245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11154103T00000X
MA3927103K00000X
MEPS1836103T00000X
NY023447103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst