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General NPI Number Information
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NPI Number | 1386057925
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Entity Type | Individual
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Provider Name | DONALD MULLISON
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Gender | Male
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Dates
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Enumeration Date | 06/10/2014
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Last Update Date | 06/10/2014
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Provider Practice Location Address
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Address Line | 231 W MAIN ST SUITE 1 WEST
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City | CARBONDALE
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State | IL
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Zip | 62901-2948
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Country | US
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Telephone | 618-203-2869
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Fax |
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Provider Business Mailing Address
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Address Line | 231 W MAIN ST SUITE 1 WEST
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City | CARBONDALE
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State | IL
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Zip | 62901-2948
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071.004084
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License Number State | IL
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