Healthcare Provider Details

I. General information

NPI: 1720386683
Provider Name (Legal Business Name): ECU PASS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 RAWL BUILDING , EAST 5TH ST. EAST CAROLINA UNIVERSITY
GREENVILLE NC
27858-4353
US

IV. Provider business mailing address

311 RAWL BUILDING, DEPARTMENT OF PSYCHOLOGY EAST CAROLINA UNIVERSITY
GREENVILLE NC
27858-4353
US

V. Phone/Fax

Practice location:
  • Phone: 252-737-4180
  • Fax: 252-737-4166
Mailing address:
  • Phone: 252-737-4180
  • Fax: 252-737-4166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1018
License Number StateNC

VIII. Authorized Official

Name: DR. TONY CELLUCCI
Title or Position: CLINIC DIRECTOR
Credential: PH.D.
Phone: 252-737-4179