Provider Demographics
NPI:1861528978
Name:KATHLEEN MCNULTY
Entity type:Organization
Organization Name:KATHLEEN MCNULTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-444-4010
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:201-768-1644
Mailing Address - Fax:
Practice Address - Street 1:15 GODWIN AVE
Practice Address - Street 2:# 2
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3705
Practice Address - Country:US
Practice Address - Phone:201-444-4010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC008404001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ640426Medicare PIN