Provider Demographics
NPI:1942228721
Name:GULLO-JENNE, CAROL ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANNE
Last Name:GULLO-JENNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 LOUISA AVE
Mailing Address - Street 2:SUITE 118
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-4669
Mailing Address - Country:US
Mailing Address - Phone:757-333-7797
Mailing Address - Fax:757-333-7760
Practice Address - Street 1:324 LOUISA AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4669
Practice Address - Country:US
Practice Address - Phone:757-333-7797
Practice Address - Fax:757-333-7760
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040004561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAO80372OtherSENTARA OPTIMA HEALTH CAR
VA063739OtherANTHEM BCBS OF VA
VA226446000OtherMAGELLAN
VA8910197Medicaid
VAO80372OtherSENTARA OPTIMA HEALTH CAR