Healthcare Provider Details

I. General information

NPI: 1588272363
Provider Name (Legal Business Name): REBECCA L MCMULLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 INDUSTRY WAY
LYNWOOD CA
90262-4284
US

IV. Provider business mailing address

2640 INDUSTRY WAY
LYNWOOD CA
90262-4284
US

V. Phone/Fax

Practice location:
  • Phone: 310-627-4525
  • Fax:
Mailing address:
  • Phone: 310-627-4525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number113952
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number75790
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: