Provider Demographics
NPI:1982168688
Name:DILULLO, PHETSAMON
Entity Type:Individual
Prefix:
First Name:PHETSAMON
Middle Name:
Last Name:DILULLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2922
Mailing Address - Country:US
Mailing Address - Phone:860-973-9171
Mailing Address - Fax:
Practice Address - Street 1:32 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2922
Practice Address - Country:US
Practice Address - Phone:860-973-9171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-27
Last Update Date:2019-04-12
Deactivation Date:2019-02-11
Deactivation Code:
Reactivation Date:2019-04-12
Provider Licenses
StateLicense IDTaxonomies
CT0101631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical