Healthcare Provider Details

I. General information

NPI: 1558769786
Provider Name (Legal Business Name): LAURA MULLIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 04/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 VETERANS PKWY S
MOULTRIE GA
31788-6705
US

IV. Provider business mailing address

3015 VETERANS PKWY S
MOULTRIE GA
31788-6705
US

V. Phone/Fax

Practice location:
  • Phone: 229-985-4815
  • Fax:
Mailing address:
  • Phone: 229-873-6479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW005190
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: