Individual
MR. PASQUALE JOHN RUSSONIELLO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.A.
Contact information
Practice address
366 FAIRFAX RD, DREXEL HILL, PA 19026-1007
(610) 316-6944
Mailing address
366 FAIRFAX RD, DREXEL HILL, PA 19026-1007
(610) 316-6944
(215) 289-1463
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
PS002904-L
PA
103TC0700X
Clinical Psychologist
PS002904L
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11706713
CAQH
PA
Enumeration date
05/17/2007
Last updated
10/01/2021
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