Provider Demographics
NPI:1215975297
Name:MCNULTY, WALTER H (PHD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:H
Last Name:MCNULTY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 S SHARON AMITY RD STE 304
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2886
Mailing Address - Country:US
Mailing Address - Phone:704-716-1006
Mailing Address - Fax:704-366-6464
Practice Address - Street 1:1008 UNION RD STE C
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5590
Practice Address - Country:US
Practice Address - Phone:704-716-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1923103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000538Medicaid
2814441CMedicare ID - Type Unspecified