Basic Information
| Provider Information | |||||||||
| NPI: | 1063990604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLIGAN | ||||||||
| FirstName: | LIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2130 SPRING GARDEN ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191303502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159559555 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159558962 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2018 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 44SC05597500 | NJ | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | CW018559 | PA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.