Provider Demographics
NPI:1912380965
Name:MCNULTY, MARION (PSYD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 SW BARNES RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6638
Mailing Address - Country:US
Mailing Address - Phone:503-216-4965
Mailing Address - Fax:
Practice Address - Street 1:9450 SW BARNES RD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6638
Practice Address - Country:US
Practice Address - Phone:503-216-4965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0656106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist