Provider Demographics
NPI:1497896906
Name:NULTON, LARRY J (PHD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:J
Last Name:NULTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 COLLEGE PARK PLZ
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-2833
Mailing Address - Country:US
Mailing Address - Phone:814-262-0025
Mailing Address - Fax:814-266-8745
Practice Address - Street 1:214 COLLEGE PARK PLZ
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-2833
Practice Address - Country:US
Practice Address - Phone:814-262-0025
Practice Address - Fax:814-266-8745
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007732L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1524550Medicaid
PA681467PTYMedicare ID - Type Unspecified
PA1524550Medicaid