Provider Demographics
NPI:1811018229
Name:MCNULTY, MICHELE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:MCNULTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:7439 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-3076
Mailing Address - Country:US
Mailing Address - Phone:856-663-9313
Mailing Address - Fax:
Practice Address - Street 1:90 BRICK RD
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2177
Practice Address - Country:US
Practice Address - Phone:856-355-6082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00619700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist