Provider Demographics
NPI:1790255198
Name:MASCOLO, MICHAEL (SLP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MASCOLO
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 ARABIAN DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-8027
Mailing Address - Country:US
Mailing Address - Phone:251-979-3119
Mailing Address - Fax:
Practice Address - Street 1:2213 ROUND HILL DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-8855
Practice Address - Country:US
Practice Address - Phone:757-648-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000175235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist