Healthcare Provider Details

I. General information

NPI: 1790255198
Provider Name (Legal Business Name): MICHAEL MASCOLO SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2213 ROUND HILL DR
VIRGINIA BEACH VA
23464-8855
US

IV. Provider business mailing address

2605 ARABIAN DR
VIRGINIA BEACH VA
23456-8027
US

V. Phone/Fax

Practice location:
  • Phone: 757-648-2520
  • Fax:
Mailing address:
  • Phone: 251-979-3119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2204000175
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: