Provider Demographics
NPI:1720386683
Name:ECU PASS CLINIC
Entity Type:Organization
Organization Name:ECU PASS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:CELLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:252-737-4179
Mailing Address - Street 1:311 RAWL BUILDING, DEPARTMENT OF PSYCHOLOGY
Mailing Address - Street 2:EAST CAROLINA UNIVERSITY
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-4353
Mailing Address - Country:US
Mailing Address - Phone:252-737-4180
Mailing Address - Fax:252-737-4166
Practice Address - Street 1:311 RAWL BUILDING , EAST 5TH ST.
Practice Address - Street 2:EAST CAROLINA UNIVERSITY
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-4353
Practice Address - Country:US
Practice Address - Phone:252-737-4180
Practice Address - Fax:252-737-4166
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST CAROLINA UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1018103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty