Provider Demographics
NPI:1144082447
Name:MCNULTY, BENJAMIN (OTD, OTRL)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:M
Credentials:OTD, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 SELKIRK ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3927
Mailing Address - Country:US
Mailing Address - Phone:734-751-7969
Mailing Address - Fax:
Practice Address - Street 1:22731 NEWMAN ST STE 100B
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2023
Practice Address - Country:US
Practice Address - Phone:313-791-0616
Practice Address - Fax:313-791-0632
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013755225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist