Provider Demographics
NPI:1194798108
Name:VICCHIULLO, CAROLYN IRMA (PSYD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:IRMA
Last Name:VICCHIULLO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 UPSTREAM FARM RD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040
Mailing Address - Country:US
Mailing Address - Phone:610-248-1797
Mailing Address - Fax:610-253-7062
Practice Address - Street 1:2030 LEHIGH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042
Practice Address - Country:US
Practice Address - Phone:610-253-8900
Practice Address - Fax:610-253-7062
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015116103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA03183600OtherCBC
PA262019000OtherMAGELLAN