Provider Demographics
NPI:1194878918
Name:MCNULTY, MICHAEL ANTHONY (MSW, PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:MCNULTY
Suffix:
Gender:M
Credentials:MSW, PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 CHURCH ST
Mailing Address - Street 2:SUITE 233
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3875
Mailing Address - Country:US
Mailing Address - Phone:847-328-0106
Mailing Address - Fax:
Practice Address - Street 1:708 CHURCH ST
Practice Address - Street 2:SUITE 233
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3875
Practice Address - Country:US
Practice Address - Phone:847-328-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL958701Medicare ID - Type Unspecified