Provider Demographics
NPI:1912498718
Name:MARCUCELLA, HENRY
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:MARCUCELLA
Suffix:
Gender:M
Credentials:
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 62
Mailing Address - Street 2:
Mailing Address - City:EASTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02642-0062
Mailing Address - Country:US
Mailing Address - Phone:617-230-2309
Mailing Address - Fax:
Practice Address - Street 1:795 KINGSBURY BEACH ROAD
Practice Address - Street 2:
Practice Address - City:EASTHAM
Practice Address - State:MA
Practice Address - Zip Code:02642-0062
Practice Address - Country:US
Practice Address - Phone:617-230-2309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FM559-PY-PR103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty