Provider Demographics
NPI:1972712149
Name:MCMULLEN, CONNIE LAVERNE (MS LPC NCC)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:LAVERNE
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:MS LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8193 SW 82ND PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6995
Mailing Address - Country:US
Mailing Address - Phone:503-244-6616
Mailing Address - Fax:503-246-4446
Practice Address - Street 1:10260 SW GREENBURG RD
Practice Address - Street 2:473
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-5500
Practice Address - Country:US
Practice Address - Phone:503-544-8221
Practice Address - Fax:503-246-4446
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
55781101Y00000X
ORC1724101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor