Healthcare Provider Details

I. General information

NPI: 1073901310
Provider Name (Legal Business Name): THERESA ANN MARULLI LPCC- S , LICDC-CS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3445 S MAIN ST
COVENTRY TOWNSHIP OH
44319-3028
US

IV. Provider business mailing address

3445 S MAIN ST
COVENTRY TOWNSHIP OH
44319-3028
US

V. Phone/Fax

Practice location:
  • Phone: 330-644-4095
  • Fax: 330-645-2031
Mailing address:
  • Phone: 330-644-4095
  • Fax: 330-645-2031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE0004947
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number981328
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: