Provider Demographics
NPI:1619220514
Name:RUSSOLI, ROLAND ITALO JR (MSW)
Entity Type:Individual
Prefix:MR
First Name:ROLAND
Middle Name:ITALO
Last Name:RUSSOLI
Suffix:JR
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:ROLAND
Other - Middle Name:
Other - Last Name:RUSSOLI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, MHP
Mailing Address - Street 1:3322 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4425
Mailing Address - Country:US
Mailing Address - Phone:425-349-7289
Mailing Address - Fax:
Practice Address - Street 1:3322 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4425
Practice Address - Country:US
Practice Address - Phone:425-349-7289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASA60173796101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health