MEDICARE: MRS. COLLEEN MARIE MULLIN 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	44SC05178500	NJ
2	1041C0700X	Clinical Social Worker	078503-1	NY

General Provider Information

NPI Number	:	1477729085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. COLLEEN MARIE MULLIN LCSW

Provider Business Mailing Address
First Line	:	120 MEADOW ST
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-6615
Country	:	US
Telephone Number	:	201-694-0897
Fax Number	:	201-694-0897

Provider Business Practice Location Address
First Line	:	120 MEADOW ST
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-6615
Country	:	US
Telephone Number	:	201-694-0897
Fax Number	:	201-694-0897

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

Provider Enumeration Date	:	05/03/2008
Last Update Date	:	11/18/2020

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