Provider Demographics
NPI:1194163055
Name:MULLINS, ALICIA KAY
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:KAY
Last Name:MULLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6655
Mailing Address - Fax:270-858-4607
Practice Address - Street 1:601 LINCOLN PARK ROAD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:KY
Practice Address - Zip Code:40069-1501
Practice Address - Country:US
Practice Address - Phone:844-435-0900
Practice Address - Fax:270-858-4029
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR104100000X
AR7172-C1041C0700X
KY2542111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100606470Medicaid