Healthcare Provider Details

I. General information

NPI: 1386126753
Provider Name (Legal Business Name): SOPHIA MULLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2018
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 WASHINGTON AVE N
MINNEAPOLIS MN
55401-2263
US

IV. Provider business mailing address

4749 16TH AVE S
MINNEAPOLIS MN
55407-3606
US

V. Phone/Fax

Practice location:
  • Phone: 612-825-4792
  • Fax: 626-727-7535
Mailing address:
  • Phone: 804-467-4592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP7320
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: