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
1	101Y00000X	Counselor	55781
2	101YP2500X	Professional Counselor	C1724	OR

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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