Provider Demographics
NPI:1669424636
Name:FIRULLO, LISA ANN (LPC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:FIRULLO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1467
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-1467
Mailing Address - Country:US
Mailing Address - Phone:704-941-9419
Mailing Address - Fax:
Practice Address - Street 1:903 NORTHEAST DR
Practice Address - Street 2:SUITE 301
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7416
Practice Address - Country:US
Practice Address - Phone:704-941-9419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4287101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102348Medicaid