Provider Demographics
NPI:1053561985
Name:MULLIGAN, LORI (MA, LMHC, CASAC)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:MA, LMHC, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4108 MAKYES RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-8708
Mailing Address - Country:US
Mailing Address - Phone:315-751-4704
Mailing Address - Fax:
Practice Address - Street 1:4108 MAKYES RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-8708
Practice Address - Country:US
Practice Address - Phone:315-751-4704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20064101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01079267Medicaid