Basic Information
| Provider Information | |||||||||
| NPI: | 1649474834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULL | ||||||||
| FirstName: | MINDA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CDCI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 S CUSHMAN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074526251 | ||||||||
| FaxNumber: | 9074564849 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 S CUSHMAN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074526251 | ||||||||
| FaxNumber: | 9074564849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YA0400X | 2934 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.