Provider Demographics
NPI:1669528162
Name:MCNULTY, VIRGINIA SAMEL (LCSW)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:SAMEL
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10187
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-5187
Mailing Address - Country:US
Mailing Address - Phone:207-777-4111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:100 CAMPUS AVE
Practice Address - Street 2:SUITES A & B
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6040
Practice Address - Country:US
Practice Address - Phone:207-755-3434
Practice Address - Fax:207-784-6826
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC69741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical