Provider Demographics
NPI:1023027414
Name:MCNULTY, KATHLEEN FENNO (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:FENNO
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 MOUND AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-3350
Mailing Address - Country:US
Mailing Address - Phone:262-633-3591
Mailing Address - Fax:262-633-2619
Practice Address - Street 1:1220 MOUND AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-3350
Practice Address - Country:US
Practice Address - Phone:262-633-3591
Practice Address - Fax:262-633-2619
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7210-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40984300Medicaid