Provider Demographics
NPI:1821218819
Name:FASANELLO, SEBASTIAN SALVATORE (MD)
Entity Type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:SALVATORE
Last Name:FASANELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-2708
Mailing Address - Country:US
Mailing Address - Phone:716-828-9811
Mailing Address - Fax:716-828-9363
Practice Address - Street 1:150 MARTIN RD
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-2708
Practice Address - Country:US
Practice Address - Phone:716-828-9811
Practice Address - Fax:716-828-9363
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090320322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children