Individual
MICHAEL JOHN MCMULLEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LAC
Contact information
Practice address
4227 9TH AVE S, FARGO, ND 58103-2018
(701) 781-6021
Mailing address
4227 9TH AVE S, FARGO, ND 58103-2018
(701) 781-6021
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
1859
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
510183396
SHAREHOUSE
ND
05
—
510183396
—
ND
Enumeration date
08/15/2019
Last updated
08/15/2019
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