Provider Demographics
NPI:1366622995
Name:MCNULTY, MAUREEN (PSYD, HSPP)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8555 TAFT ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6123
Practice Address - Country:US
Practice Address - Phone:219-769-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042377A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical