Provider Demographics
NPI:1679386486
Name:MULLEN, SHANE D
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:D
Last Name:MULLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 N BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-2919
Mailing Address - Country:US
Mailing Address - Phone:402-831-0009
Mailing Address - Fax:
Practice Address - Street 1:2112 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4670
Practice Address - Country:US
Practice Address - Phone:308-398-5427
Practice Address - Fax:308-398-5404
Is Sole Proprietor?:No
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-2248101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)