Provider Demographics
NPI:1932719499
Name:MCMULLEN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MCMULLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 144TH STREET CT S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-3337
Mailing Address - Country:US
Mailing Address - Phone:253-503-9545
Mailing Address - Fax:
Practice Address - Street 1:903 144TH STREET CT S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-3337
Practice Address - Country:US
Practice Address - Phone:253-503-9545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-08
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB60996183103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty