Provider Demographics
NPI:1407038540
Name:FASULLO, MARSHA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:ANN
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 1:314 CHERRY BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-2758
Mailing Address - Country:US
Mailing Address - Phone:504-388-3258
Mailing Address - Fax:504-263-1556
Practice Address - Street 1:433 METAIRIE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70005-4333
Practice Address - Country:US
Practice Address - Phone:504-835-5007
Practice Address - Fax:504-835-5018
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical