Provider Demographics
NPI:1609247964
Name:SOUTULLO, KAREN MICHELLE
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MICHELLE
Last Name:SOUTULLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 VILLAGE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4514
Mailing Address - Country:US
Mailing Address - Phone:615-463-6669
Mailing Address - Fax:910-221-9006
Practice Address - Street 1:3505 VILLAGE DR STE 101
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4514
Practice Address - Country:US
Practice Address - Phone:615-463-6669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA11927101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health