Healthcare Provider Details

I. General information

NPI: 1497896906
Provider Name (Legal Business Name): LARRY J NULTON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 COLLEGE PARK PLZ
JOHNSTOWN PA
15904-2833
US

IV. Provider business mailing address

214 COLLEGE PARK PLZ
JOHNSTOWN PA
15904-2833
US

V. Phone/Fax

Practice location:
  • Phone: 814-262-0025
  • Fax: 814-266-8745
Mailing address:
  • Phone: 814-262-0025
  • Fax: 814-266-8745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS007732L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: