Provider Demographics
NPI:1871727222
Name:RUSSONIELLO, CARMEN VINCENT SR (PHD)
Entity type:Individual
Prefix:PROF
First Name:CARMEN
Middle Name:VINCENT
Last Name:RUSSONIELLO
Suffix:SR
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 1:311 KING GEORGE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5617
Mailing Address - Country:US
Mailing Address - Phone:252-353-8674
Mailing Address - Fax:
Practice Address - Street 1:BELK BUILDING SUITE 2501
Practice Address - Street 2:EAST CAROLINA UNIVERSITY
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858
Practice Address - Country:US
Practice Address - Phone:252-328-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3454101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health