Provider Demographics
NPI:1194207381
Name:MULLEN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MULLEN
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 1:269 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4727
Mailing Address - Country:US
Mailing Address - Phone:413-499-9515
Mailing Address - Fax:
Practice Address - Street 1:269 1ST ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4727
Practice Address - Country:US
Practice Address - Phone:413-499-9515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA115824-SW-LICSW156FX1202X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric Technician