Provider Demographics
NPI:1770552804
Name:MULLENS, SHERRY A (MSW)
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:A
Last Name:MULLENS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:SHERRY
Other - Middle Name:A
Other - Last Name:GELENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4316
Mailing Address - Street 2:93 CULTON LANE
Mailing Address - City:TUBAC
Mailing Address - State:AZ
Mailing Address - Zip Code:85646-4316
Mailing Address - Country:US
Mailing Address - Phone:520-398-2370
Mailing Address - Fax:520-398-2746
Practice Address - Street 1:AMADO TERRITORY RANCH
Practice Address - Street 2:3001 E. FRONTAGE RD.
Practice Address - City:AMADO
Practice Address - State:AZ
Practice Address - Zip Code:85645
Practice Address - Country:US
Practice Address - Phone:520-398-2370
Practice Address - Fax:520-398-2746
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW 105771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ926454Medicaid
AZ101751Medicare ID - Type Unspecified
AZ926454Medicaid