Provider Demographics
NPI:1871604066
Name:CERULLI, THERESA ROSE (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ROSE
Last Name:CERULLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:CERULLI-BANKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4 BRISTOL LN
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-5813
Mailing Address - Country:US
Mailing Address - Phone:978-475-0592
Mailing Address - Fax:
Practice Address - Street 1:790 TURNPIKE ST
Practice Address - Street 2:SUITE 106
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-6144
Practice Address - Country:US
Practice Address - Phone:978-683-6065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1523032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3169324Medicaid
MA3169324Medicaid
G49660Medicare UPIN