Healthcare Provider Details

I. General information

NPI: 1194946681
Provider Name (Legal Business Name): TIMOTHY JOHN MULLEN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 KINDERHOOK STREET
CHATHAM NY
12037
US

IV. Provider business mailing address

61 DUNHAM HOLLOW ROAD
EAST NASSAU NY
12062
US

V. Phone/Fax

Practice location:
  • Phone: 518-392-2160
  • Fax:
Mailing address:
  • Phone: 518-766-6457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number013056-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: