MEDICARE: MRS. KATHLEEN FENNO MCNULTY L.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	7210-123	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023027414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN FENNO MCNULTY L.C.S.W.

Provider Business Mailing Address
First Line	:	1220 MOUND AVE
Second Line	:	SUITE 301
City	:	RACINE
State	:	WI
Zip	:	53404-3350
Country	:	US
Telephone Number	:	262-633-3591
Fax Number	:	262-633-2619

Provider Business Practice Location Address
First Line	:	1220 MOUND AVE
Second Line	:	SUITE 301
City	:	RACINE
State	:	WI
Zip	:	53404-3350
Country	:	US
Telephone Number	:	262-633-3591
Fax Number	:	262-633-2619

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/08/2007

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