Healthcare Provider Details

I. General information

NPI: 1952898561
Provider Name (Legal Business Name): AMY COULTER SCHULLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463 SWANSEA MALL DR
SWANSEA MA
02777-4119
US

IV. Provider business mailing address

889 HOPE ST
BRISTOL RI
02809-1108
US

V. Phone/Fax

Practice location:
  • Phone: 508-324-4202
  • Fax:
Mailing address:
  • Phone: 504-417-0774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW229067
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number14218
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: