Healthcare Provider Details

I. General information

NPI: 1295901809
Provider Name (Legal Business Name): MARILYN MULL L.C.S.W. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2008
Last Update Date: 05/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 SE OAK AVE 347
ROSEBURG OR
97470-4985
US

IV. Provider business mailing address

PO BOX 1516
ROSEBURG OR
97470-0358
US

V. Phone/Fax

Practice location:
  • Phone: 541-672-7142
  • Fax:
Mailing address:
  • Phone: 541-672-7142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1242
License Number StateOR

VIII. Authorized Official

Name: MS. MARILYN MULL
Title or Position: PRESIDENT
Credential: LCSW
Phone: 541-672-7142