Provider Demographics
NPI:1891343430
Name:MULLIN, DEBRA SUE (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:SUE
Last Name:MULLIN
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 LEON ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5510
Mailing Address - Country:US
Mailing Address - Phone:904-540-6218
Mailing Address - Fax:
Practice Address - Street 1:4320 A1A S STE 7
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-7436
Practice Address - Country:US
Practice Address - Phone:904-679-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6826235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist