Provider Demographics
NPI:1750836078
Name:RUSSOLELLO, DOMENICK
Entity Type:Individual
Prefix:
First Name:DOMENICK
Middle Name:
Last Name:RUSSOLELLO
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 1:16 MAYBROOK RD
Mailing Address - Street 2:STE A
Mailing Address - City:CAMPBELL HALL
Mailing Address - State:NY
Mailing Address - Zip Code:10916-2743
Mailing Address - Country:US
Mailing Address - Phone:845-636-4344
Mailing Address - Fax:845-636-4355
Practice Address - Street 1:1141 ROUTE 55
Practice Address - Street 2:STE A
Practice Address - City:LAGRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540-5005
Practice Address - Country:US
Practice Address - Phone:845-895-1115
Practice Address - Fax:845-895-1116
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist