Provider Demographics
NPI:1326006735
Name:FASULLO, DONNA (LCSW)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:FASULLO
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 1:3027 MARINA BAY DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2729
Mailing Address - Country:US
Mailing Address - Phone:713-687-7644
Mailing Address - Fax:281-240-6481
Practice Address - Street 1:3027 MARINA BAY DR
Practice Address - Street 2:SUITE 110
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2729
Practice Address - Country:US
Practice Address - Phone:713-687-7644
Practice Address - Fax:281-240-6481
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1041C0700X1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146355602Medicaid
TX00S03POtherBC/BS
TX124104401Medicaid
TX124104401Medicaid
TX146355602Medicaid