Provider Demographics
NPI:1396936597
Name:MASSULLO, BRANDON (MA/LPCC)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:MASSULLO
Suffix:
Gender:M
Credentials:MA/LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24500 CENTER RIDGE RD
Mailing Address - Street 2:BUILDING 4, SUITE 100
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5601
Mailing Address - Country:US
Mailing Address - Phone:440-899-1300
Mailing Address - Fax:440-899-0266
Practice Address - Street 1:24500 CENTER RIDGE RD
Practice Address - Street 2:BUILDING 4, SUITE 100
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5601
Practice Address - Country:US
Practice Address - Phone:440-899-1300
Practice Address - Fax:440-899-0266
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0900008101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional