Provider Demographics
NPI:1770619066
Name:MCNULTY, KATHLEEN (LCSW, PHD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07647-1219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 GODWIN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1927
Practice Address - Country:US
Practice Address - Phone:201-444-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC008404001041C0700X
106H00000X
NJ35S100513600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ640426Medicare PIN