Provider Demographics
NPI:1386057925
Name:MULLISON, DONALD
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:MULLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 W MAIN ST
Mailing Address - Street 2:SUITE 1 WEST
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:231 W MAIN ST
Practice Address - Street 2:SUITE 1 WEST
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2948
Practice Address - Country:US
Practice Address - Phone:618-203-2869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.004084103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical