Healthcare Provider Details

I. General information

NPI: 1154513323
Provider Name (Legal Business Name): MELISSA D MULLER LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 SOUTHPARK CIR E
ST AUGUSTINE FL
32086-5137
US

IV. Provider business mailing address

123 MENENDEZ RD
ST AUGUSTINE FL
32080-5327
US

V. Phone/Fax

Practice location:
  • Phone: 907-617-2372
  • Fax: 904-797-5681
Mailing address:
  • Phone: 907-617-2372
  • Fax: 904-797-5681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number516
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: