Provider Demographics
NPI:1255615571
Name:VINCENT J FUSELLA PHD PC
Entity type:Organization
Organization Name:VINCENT J FUSELLA PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:FUSELLA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:732-636-6165
Mailing Address - Street 1:ONE WOODBRIDGE CENTER
Mailing Address - Street 2:SUITE 505
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095
Mailing Address - Country:US
Mailing Address - Phone:732-636-6165
Mailing Address - Fax:732-636-6172
Practice Address - Street 1:ONE WOODBRIDGE CENTER
Practice Address - Street 2:SUITE 505
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095
Practice Address - Country:US
Practice Address - Phone:732-636-6165
Practice Address - Fax:732-636-6172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00118000103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1646206Medicaid
R31406Medicare UPIN