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NPI Code Detail

MEDICARE: MS. CONNIE LAVERNE MCMULLEN MS LPC NCC

MEDICARE: MS. CONNIE LAVERNE MCMULLEN MS LPC NCC
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
1101Y00000XCounselor55781
2101YP2500XProfessional CounselorC1724OR

General Provider Information

NPI Number : 1972712149
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. CONNIE LAVERNE MCMULLEN MS LPC NCC
Provider Business Mailing Address
First Line : 8193 SW 82ND PL
Second Line :
City : PORTLAND
State : OR
Zip : 97223-6995
Country : US
Telephone Number : 503-244-6616
Fax Number : 503-246-4446
Provider Business Practice Location Address
First Line : 10260 SW GREENBURG RD
Second Line : 473
City : PORTLAND
State : OR
Zip : 97223-5500
Country : US
Telephone Number : 503-544-8221
Fax Number : 503-246-4446
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/22/2007
Last Update Date : 06/02/2016

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