Healthcare Provider Details

I. General information

NPI: 1578549176
Provider Name (Legal Business Name): TIMOTHY M MULLEN OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LEFFINGWELL AVE NE SUITE 200
GRAND RAPIDS MI
49525-6406
US

IV. Provider business mailing address

1111 LEFFINGWELL AVE NE SUITE 200
GRAND RAPIDS MI
49525-6406
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7101
  • Fax: 616-954-6483
Mailing address:
  • Phone: 616-459-7101
  • Fax: 616-954-6483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number5201002530
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: