Provider Demographics
NPI:1609913201
Name:PESANIELLO, JOHN P (LCADC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:PESANIELLO
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5242 PEARL DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHINCOTEAGUE
Mailing Address - State:VA
Mailing Address - Zip Code:23336
Mailing Address - Country:US
Mailing Address - Phone:757-336-3535
Mailing Address - Fax:
Practice Address - Street 1:422 W MARKET STREET
Practice Address - Street 2:WORCESTER COUNTY HEALTH DEPARTMENT MARKET SQUARE
Practice Address - City:SNOW HILL
Practice Address - State:MD
Practice Address - Zip Code:21863
Practice Address - Country:US
Practice Address - Phone:410-632-4510
Practice Address - Fax:410-632-4933
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA293101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS013Medicare ID - Type Unspecified