Provider Demographics
NPI:1518086735
Name:DAVID L MARASCIULLO PH.D,PSYCHOLOGIST, PC
Entity Type:Organization
Organization Name:DAVID L MARASCIULLO PH.D,PSYCHOLOGIST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:MARASCIULLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:631-643-7390
Mailing Address - Street 1:18 S HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-6140
Mailing Address - Country:US
Mailing Address - Phone:631-643-7390
Mailing Address - Fax:631-643-5068
Practice Address - Street 1:18 S HOLLOW RD
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6140
Practice Address - Country:US
Practice Address - Phone:631-643-7390
Practice Address - Fax:631-643-5068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3879103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS0879-4 BOtherWORKERS' COMPENSATION
NY3879OtherPSYCHOLOGY LICENSE
NY02927659Medicaid
NY02927659Medicaid
NYVWW621Medicare Oscar/Certification
NYR50811Medicare UPIN