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General NPI Number Information
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NPI Number | 1679386486
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Entity Type | Individual
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Provider Name | SHANE D MULLEN
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Gender | Male
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Dates
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Enumeration Date | 01/28/2025
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Last Update Date | 01/28/2025
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Provider Practice Location Address
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Address Line | 2112 W FAIDLEY AVE
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City | GRAND ISLAND
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State | NE
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Zip | 68803-4670
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Country | US
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Telephone | 308-398-5427
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Fax | 308-398-5404
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Provider Business Mailing Address
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Address Line | 1342 N BALTIMORE AVE
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City | HASTINGS
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State | NE
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Zip | 68901-2919
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Country | US
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Telephone | 402-831-0009
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | P-2248
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License Number State | NE
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