Provider Demographics
NPI:1346344413
Name:MARULLO, SAM JR (PHD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:MARULLO
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16821 BUCCANEER LN STE 240
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2542
Mailing Address - Country:US
Mailing Address - Phone:281-488-0615
Mailing Address - Fax:281-488-1390
Practice Address - Street 1:16821 BUCCANEER LN STE 240
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2542
Practice Address - Country:US
Practice Address - Phone:281-488-0615
Practice Address - Fax:281-488-1390
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22392103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100260201Medicaid
00TN27Medicare UPIN
TX100260201Medicaid