Provider Demographics
NPI:1740793850
Name:PASSARELLI, RYAN M
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:PASSARELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CHIPMUNK TRL
Mailing Address - Street 2:
Mailing Address - City:SANDY HOOK
Mailing Address - State:CT
Mailing Address - Zip Code:06482-1135
Mailing Address - Country:US
Mailing Address - Phone:203-364-6802
Mailing Address - Fax:
Practice Address - Street 1:731 MAIN ST STE 122
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2872
Practice Address - Country:US
Practice Address - Phone:203-364-6802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3316101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional