Healthcare Provider Details

I. General information

NPI: 1437408713
Provider Name (Legal Business Name): YVONNE C MCNULTY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2012
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 CRANBERRY HWY STE 5
WAREHAM MA
02571-1019
US

IV. Provider business mailing address

27 PLEASANT ST
WAREHAM MA
02571
US

V. Phone/Fax

Practice location:
  • Phone: 774-384-8286
  • Fax:
Mailing address:
  • Phone: 508-274-4463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number119759
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: