Provider Demographics
NPI:1306052253
Name:MULLAVEY, EDWIN THOMAS JR (PCC)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:THOMAS
Last Name:MULLAVEY
Suffix:JR
Gender:M
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SUMMIT AVENUE.
Mailing Address - Street 2:TOWER TWO ROOM TEN
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952
Mailing Address - Country:US
Mailing Address - Phone:740-283-7860
Mailing Address - Fax:740-283-7853
Practice Address - Street 1:380 SUMMIT AVE
Practice Address - Street 2:TOWER TWO ROOM TEN
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-2667
Practice Address - Country:US
Practice Address - Phone:740-283-7860
Practice Address - Fax:740-283-7853
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE 0003333101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health