Healthcare Provider Details

I. General information

NPI: 1740921949
Provider Name (Legal Business Name): PETER MULLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JORIE BLVD STE 228
OAK BROOK IL
60523-4481
US

IV. Provider business mailing address

1000 JORIE BLVD STE 228
OAK BROOK IL
60523-4481
US

V. Phone/Fax

Practice location:
  • Phone: 630-912-7763
  • Fax:
Mailing address:
  • Phone: 630-912-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.023345
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: