Healthcare Provider Details

I. General information

NPI: 1033822432
Provider Name (Legal Business Name): TOMMIE MCMULLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2022
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 CHAMPLAIN ST
TOLEDO OH
43604-2041
US

IV. Provider business mailing address

4181 E 96TH ST STE 120
INDIANAPOLIS IN
46240-3814
US

V. Phone/Fax

Practice location:
  • Phone: 567-806-5120
  • Fax:
Mailing address:
  • Phone: 317-743-9823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: