Provider Demographics
NPI:1871015545
Name:MULLEN, AUDREY (OTR/L)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MULLEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31488 MIDDLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LANARK
Mailing Address - State:IL
Mailing Address - Zip Code:61046-9039
Mailing Address - Country:US
Mailing Address - Phone:815-499-2045
Mailing Address - Fax:
Practice Address - Street 1:1010 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6600
Practice Address - Country:US
Practice Address - Phone:815-599-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008765225X00000X
SC4432225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist