Provider Demographics
NPI:1194946681
Name:MULLEN, TIMOTHY JOHN (LMT)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:MULLEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 DUNHAM HOLLOW ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST NASSAU
Mailing Address - State:NY
Mailing Address - Zip Code:12062
Mailing Address - Country:US
Mailing Address - Phone:518-766-6457
Mailing Address - Fax:
Practice Address - Street 1:25 KINDERHOOK STREET
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NY
Practice Address - Zip Code:12037
Practice Address - Country:US
Practice Address - Phone:518-392-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013056-1172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist