Basic Information
| Provider Information | |||||||||
| NPI: | 1629172200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACMULLEN | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | DURETTE | ||||||||
| OtherFirstName: | ERIN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 109 RHODE ISLAND RD | ||||||||
| Address2: | |||||||||
| City: | LAKEVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023471370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814895717 | ||||||||
| FaxNumber: | 5088193035 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 ESSEX GREAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018805022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812241416 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 01/19/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 729 | MA | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 5104343 | 05 | MA | MEDICAID |