Healthcare Provider Details

I. General information

NPI: 1922464957
Provider Name (Legal Business Name): MANI MULLEN CRC # 00002984
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7925 WINCHESTER BLVD
QUEENS VILLAGE NY
11427-2128
US

IV. Provider business mailing address

7925 WINCHESTER BLVD
QUEENS VILLAGE NY
11427-2128
US

V. Phone/Fax

Practice location:
  • Phone: 718-464-7500
  • Fax: 718-264-5043
Mailing address:
  • Phone: 718-464-7500
  • Fax: 718-264-5043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: