Healthcare Provider Details

I. General information

NPI: 1154838910
Provider Name (Legal Business Name): LISA MARIE VULLO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3432 DEPEW AVE
PORT CHARLOTTE FL
33952-7015
US

IV. Provider business mailing address

26314 ASUNCION DR
PUNTA GORDA FL
33983-5357
US

V. Phone/Fax

Practice location:
  • Phone: 848-422-9245
  • Fax: 848-422-9245
Mailing address:
  • Phone: 941-875-5948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW6123
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: