Provider Demographics
NPI:1366593477
Name:RUSSOLILLO, PATRICK JOSEPH (PHD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JOSEPH
Last Name:RUSSOLILLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 TIMBER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-1538
Mailing Address - Country:US
Mailing Address - Phone:860-344-9694
Mailing Address - Fax:860-346-2947
Practice Address - Street 1:154 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3201
Practice Address - Country:US
Practice Address - Phone:860-344-9694
Practice Address - Fax:860-346-2947
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0001383103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4080389Medicare ID - Type Unspecified