Provider Demographics
NPI:1205325149
Name:MULLEN, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
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 1:5 ANDREW ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-4301
Mailing Address - Country:US
Mailing Address - Phone:401-847-3708
Mailing Address - Fax:401-847-3708
Practice Address - Street 1:5 ANDREW ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-4301
Practice Address - Country:US
Practice Address - Phone:401-847-3708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2561-PY-PR103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2561-PY-PROtherPSYCHOLOGY LICENSE