Provider Demographics
NPI:1639229511
Name:MASULLO, CARMEN PHILLIP (LCSW)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:PHILLIP
Last Name:MASULLO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 WAIT AVENUE
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6985
Mailing Address - Country:US
Mailing Address - Phone:919-556-5407
Mailing Address - Fax:
Practice Address - Street 1:1331 WAIT AVE
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6985
Practice Address - Country:US
Practice Address - Phone:919-556-5407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0033151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003657Medicaid