Provider Demographics
NPI:1356659411
Name:MCNULTY, ELISE M (LLMSW)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:M
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7184 PAMELA DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1773
Mailing Address - Country:US
Mailing Address - Phone:517-403-8493
Mailing Address - Fax:
Practice Address - Street 1:500 E POTTAWATAMIE ST
Practice Address - Street 2:2 SOUTH
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-2018
Practice Address - Country:US
Practice Address - Phone:517-424-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010921151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical