Provider Demographics
NPI:1972095057
Name:MCNULTY, SAMANTHA (LPC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:509 ASPEN GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:SEVERANCE
Mailing Address - State:CO
Mailing Address - Zip Code:80550-2979
Mailing Address - Country:US
Mailing Address - Phone:303-995-1237
Mailing Address - Fax:
Practice Address - Street 1:4803 INNOVATION DR STE 3A
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-7308
Practice Address - Country:US
Practice Address - Phone:303-995-1237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
COLPC.0016667101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor