Provider Demographics
NPI:1912531567
Name:MCNULTY, TARA L
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 LOWER MILL CITY RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:PA
Mailing Address - Zip Code:18414-7870
Mailing Address - Country:US
Mailing Address - Phone:570-335-4512
Mailing Address - Fax:
Practice Address - Street 1:301 W GROVE ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-2090
Practice Address - Country:US
Practice Address - Phone:570-961-3361
Practice Address - Fax:570-961-3364
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-22
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001898103K00000X
PAPC014934101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst