Provider Demographics
NPI:1043734080
Name:MUFFULETTO, NAOMI FORTUNE
Entity type:Individual
Prefix:MRS
First Name:NAOMI
Middle Name:FORTUNE
Last Name:MUFFULETTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 TIMBERLAND TER
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7196
Mailing Address - Country:US
Mailing Address - Phone:601-906-7638
Mailing Address - Fax:
Practice Address - Street 1:1151 NORTH STATE STREET
Practice Address - Street 2:SUITE 212
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2467
Practice Address - Country:US
Practice Address - Phone:601-352-7398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2055106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist