Provider Demographics
NPI:1154838910
Name:VULLO, LISA MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:VULLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26314 ASUNCION DR
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-5357
Mailing Address - Country:US
Mailing Address - Phone:941-875-5948
Mailing Address - Fax:
Practice Address - Street 1:3432 DEPEW AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-7015
Practice Address - Country:US
Practice Address - Phone:848-422-9245
Practice Address - Fax:848-422-9245
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW61231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical