Provider Demographics
NPI:1215607494
Name:RUSSONIELLO, MATTHEW CHARLES
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHARLES
Last Name:RUSSONIELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S JEFFERSON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-3143
Mailing Address - Country:US
Mailing Address - Phone:509-768-6852
Mailing Address - Fax:
Practice Address - Street 1:400 S JEFFERSON ST STE 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-3143
Practice Address - Country:US
Practice Address - Phone:509-768-6852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61220659101Y00000X
390200000X
WAMFTA.MG.61551477106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program