Provider Demographics
NPI:1053636936
Name:MCMULLEN, ANDREA M (LICSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 US ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2146
Mailing Address - Country:US
Mailing Address - Phone:304-525-7851
Mailing Address - Fax:304-525-1073
Practice Address - Street 1:3375 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2837
Practice Address - Country:US
Practice Address - Phone:304-525-7851
Practice Address - Fax:304-525-1073
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP00943472104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005355002Medicaid
WVDP00943472OtherLICENSE
WV9122342Medicare PIN
9122432Medicare UPIN