Provider Demographics
NPI:1972607992
Name:NULTY, MAB KATHRYN (MA,LP)
Entity Type:Individual
Prefix:MS
First Name:MAB
Middle Name:KATHRYN
Last Name:NULTY
Suffix:
Gender:F
Credentials:MA,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 BELT LINE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2652
Mailing Address - Country:US
Mailing Address - Phone:952-927-4402
Mailing Address - Fax:952-927-5845
Practice Address - Street 1:3440 BELT LINE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2652
Practice Address - Country:US
Practice Address - Phone:952-927-4402
Practice Address - Fax:952-927-5845
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1447103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling