Provider Demographics
NPI:1588312003
Name:MULLETT, MENESSAH (LPC, LMHC, CYC-P)
Entity type:Individual
Prefix:
First Name:MENESSAH
Middle Name:
Last Name:MULLETT
Suffix:
Gender:F
Credentials:LPC, LMHC, CYC-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:WAKARUSA
Mailing Address - State:IN
Mailing Address - Zip Code:46573-0232
Mailing Address - Country:US
Mailing Address - Phone:574-404-3147
Mailing Address - Fax:
Practice Address - Street 1:108 W WATERFORD ST
Practice Address - Street 2:
Practice Address - City:WAKARUSA
Practice Address - State:IN
Practice Address - Zip Code:46573-2008
Practice Address - Country:US
Practice Address - Phone:574-404-3147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39004133A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health