MEDICARE: SAM MARULLO JR. PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	22392	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346344413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAM MARULLO JR. PHD

Provider Business Mailing Address
First Line	:	16821 BUCCANEER LN STE 240
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-2542
Country	:	US
Telephone Number	:	281-488-0615
Fax Number	:	281-488-1390

Provider Business Practice Location Address
First Line	:	16821 BUCCANEER LN STE 240
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-2542
Country	:	US
Telephone Number	:	281-488-0615
Fax Number	:	281-488-1390

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2006
Last Update Date	:	06/04/2021

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