Provider Demographics
NPI:1588365316
Name:MULLEN, JOSEPH CHARLES
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:CHARLES
Last Name:MULLEN
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 1:2430 MILLBROOK DR APT 202
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-1405
Mailing Address - Country:US
Mailing Address - Phone:847-602-8110
Mailing Address - Fax:
Practice Address - Street 1:2430 MILLBROOK DR
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-1403
Practice Address - Country:US
Practice Address - Phone:847-602-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL10TR0400X103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation