Healthcare Provider Details

I. General information

NPI: 1336241967
Provider Name (Legal Business Name): RUSSELL J SOTTILE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOND ST
ASBURY PARK NJ
07712-5939
US

IV. Provider business mailing address

65 WHALEPOND RD
OAKHURST NJ
07755-1246
US

V. Phone/Fax

Practice location:
  • Phone: 732-869-2766
  • Fax: 732-897-9541
Mailing address:
  • Phone: 732-263-1715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number44SC05186100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: