MEDICARE: DONNA FASULLO LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1041C0700X	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00S03P	OTHER	TX	BC/BS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326006735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA FASULLO LCSW

Provider Business Mailing Address
First Line	:	3027 MARINA BAY DR
Second Line	:	SUITE 110
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-2729
Country	:	US
Telephone Number	:	713-687-7644
Fax Number	:	281-240-6481

Provider Business Practice Location Address
First Line	:	3027 MARINA BAY DR
Second Line	:	SUITE 110
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-2729
Country	:	US
Telephone Number	:	713-687-7644
Fax Number	:	281-240-6481

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	06/23/2009

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Directions to “ DONNA FASULLO LCSW” Practice Location

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