Provider Demographics
NPI:1366568321
Name:MACMULLAN, PETER A (PSYD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
Last Name:MACMULLAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CHRISTOPHER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04097-6733
Mailing Address - Country:US
Mailing Address - Phone:207-657-5564
Mailing Address - Fax:
Practice Address - Street 1:1 VA CTR
Practice Address - Street 2:TOGUS VA MEDICAL CENTER
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6719
Practice Address - Country:US
Practice Address - Phone:207-623-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS888103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical