Provider Demographics
NPI:1417297797
Name:MCNULTY, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 452841
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-8539
Mailing Address - Country:US
Mailing Address - Phone:518-878-9042
Mailing Address - Fax:
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-846-2100
Practice Address - Fax:310-846-2139
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW60362104100000X
NY086710104100000X
CALCSW766921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker