Provider Demographics
NPI:1104936954
Name:RUSCELLI, VINCENT (PHD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:RUSCELLI
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 1:560 BLOSSOM SUITE B
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598
Mailing Address - Country:US
Mailing Address - Phone:281-338-1382
Mailing Address - Fax:281-613-1362
Practice Address - Street 1:560 BLOSSOM SUITE B
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598
Practice Address - Country:US
Practice Address - Phone:281-338-1382
Practice Address - Fax:281-613-1362
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21088103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000AR418Medicaid
TXP000AR418Medicaid