Provider Demographics
NPI:1275740029
Name:RUSSONIELLO, PASQUALE JOHN (MA)
Entity Type:Individual
Prefix:MR
First Name:PASQUALE
Middle Name:JOHN
Last Name:RUSSONIELLO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 FAIRFAX RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-1007
Mailing Address - Country:US
Mailing Address - Phone:610-316-6944
Mailing Address - Fax:215-289-1463
Practice Address - Street 1:366 FAIRFAX RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-1007
Practice Address - Country:US
Practice Address - Phone:610-316-6944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002904L103TC0700X
PAPS002904-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11706713OtherCAQH