Provider Demographics
NPI:1649358862
Name:MULLAN, LAUREN JENNIFER (MA, OTR/L)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:JENNIFER
Last Name:MULLAN
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:OCCUPATIONAL
Other - Middle Name:THERAPY
Other - Last Name:SOUTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3022 CHISHOLM CT
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7865
Mailing Address - Country:US
Mailing Address - Phone:704-843-1007
Mailing Address - Fax:704-843-1007
Practice Address - Street 1:3022 CHISHOLM CT
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-7865
Practice Address - Country:US
Practice Address - Phone:704-843-1007
Practice Address - Fax:704-843-1007
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6110225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301928Medicaid
NC1424UOtherBCBS