Healthcare Provider Details

I. General information

NPI: 1639229511
Provider Name (Legal Business Name): CARMEN PHILLIP MASULLO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 10/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 WAIT AVE
WAKE FOREST NC
27587-6985
US

IV. Provider business mailing address

1331 WAIT AVENUE
WAKE FOREST NC
27587-6985
US

V. Phone/Fax

Practice location:
  • Phone: 919-556-5407
  • Fax:
Mailing address:
  • Phone: 919-556-5407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC003315
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6003657
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: