Basic Information
Provider Information | |||||||||
NPI: | 1184879066 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MULLEN | ||||||||
FirstName: | MIRA | ||||||||
MiddleName: | LOUDA | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC, NCC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 222 TONGASS DR | ||||||||
Address2: |   | ||||||||
City: | SITKA | ||||||||
State: | AK | ||||||||
PostalCode: | 998359416 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9079662411 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3245 HOSPITAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | JUNEAU | ||||||||
State: | AK | ||||||||
PostalCode: | 99801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9073644432 | ||||||||
FaxNumber: | 9073641539 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2008 | ||||||||
LastUpdateDate: | 10/04/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 550 | AK | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 550 | 01 | AK | STATE OF ALASKA | OTHER |