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General NPI Number Information
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NPI Number | 1720386683
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Entity Type | Organization
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Legal Business Name | ECU PASS CLINIC
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Dates
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Enumeration Date | 03/02/2011
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Last Update Date | 03/02/2011
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Provider Practice Location Address
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Address Line | 311 RAWL BUILDING , EAST 5TH ST. EAST CAROLINA UNIVERSITY
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City | GREENVILLE
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State | NC
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Zip | 27858-4353
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Country | US
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Telephone | 252-737-4180
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Fax | 252-737-4166
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Provider Business Mailing Address
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Address Line | 311 RAWL BUILDING, DEPARTMENT OF PSYCHOLOGY EAST CAROLINA UNIVERSITY
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City | GREENVILLE
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State | NC
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Zip | 27858-4353
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Country | US
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Telephone | 252-737-4180
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Fax | 252-737-4166
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DR. TONY CELLUCCI
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Credential | PH.D.
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Telephone | 252-737-4179
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1018
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License Number State | NC
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