Provider Demographics
NPI:1306963657
Name:MULLEN, KERRY B (PSYD)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:B
Last Name:MULLEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 N JEFFERSON ST
Mailing Address - Street 2:#308
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1324
Mailing Address - Country:US
Mailing Address - Phone:312-655-9206
Mailing Address - Fax:312-655-9206
Practice Address - Street 1:233 E ERIE ST
Practice Address - Street 2:SUITE 309
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2926
Practice Address - Country:US
Practice Address - Phone:312-961-1964
Practice Address - Fax:312-655-9206
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical