Provider Demographics
NPI:1306804828
Name:MCNULTY, AMY SMITH (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:SMITH
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
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Mailing Address - Street 1:3541 RANDOLPH ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211
Mailing Address - Country:US
Mailing Address - Phone:704-366-6969
Mailing Address - Fax:704-366-6464
Practice Address - Street 1:3541 RANDOLPH ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-366-6969
Practice Address - Fax:704-366-6464
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC1972103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC03128OtherBCBS