MEDICARE: TRACI DIANE MULLEN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	3168	OK

General Provider Information

NPI Number	:	1386329811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI DIANE MULLEN LCSW

Provider Business Mailing Address
First Line	:	2529 SE 13TH ST
Second Line	:
City	:	MOORE
State	:	OK
Zip	:	73160-8424
Country	:	US
Telephone Number	:	405-203-1424
Fax Number	:

Provider Business Practice Location Address
First Line	:	2529 SE 13TH ST
Second Line	:
City	:	MOORE
State	:	OK
Zip	:	73160-8424
Country	:	US
Telephone Number	:	405-203-1424
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2023
Last Update Date	:	06/14/2026

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