Provider Demographics
NPI:1639888449
Name:DISOTELL-RUSCH, CHARLOTTE MARIE (MHC-LP)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:MARIE
Last Name:DISOTELL-RUSCH
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 672
Mailing Address - Street 2:
Mailing Address - City:COPENHAGEN
Mailing Address - State:NY
Mailing Address - Zip Code:13626-0672
Mailing Address - Country:US
Mailing Address - Phone:315-982-0433
Mailing Address - Fax:315-358-4399
Practice Address - Street 1:406 POST ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:NY
Practice Address - Zip Code:13309-1206
Practice Address - Country:US
Practice Address - Phone:315-982-0433
Practice Address - Fax:315-358-4399
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115262-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health