MEDICARE: MRS. ROBERTA JACQUELINE MULLAN LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LC1420	ME

General Provider Information

NPI Number	:	1376659342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ROBERTA JACQUELINE MULLAN LADC

Provider Business Mailing Address
First Line	:	256 CRESSEY RD
Second Line	:
City	:	MONMOUTH
State	:	ME
Zip	:	04259-6804
Country	:	US
Telephone Number	:	207-933-4092
Fax Number	:

Provider Business Practice Location Address
First Line	:	256 CRESSEY RD
Second Line	:
City	:	MONMOUTH
State	:	ME
Zip	:	04259-6804
Country	:	US
Telephone Number	:	207-933-4092
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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