Provider Demographics
NPI:1043616923
Name:RUSSO, MARNI (PSYD, NCSP)
Entity Type:Individual
Prefix:
First Name:MARNI
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PSYD, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 5TH AVE RM 502
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6644
Mailing Address - Country:US
Mailing Address - Phone:917-791-0525
Mailing Address - Fax:
Practice Address - Street 1:185 MADISON AVE FL 14
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4325
Practice Address - Country:US
Practice Address - Phone:212-506-5935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024661103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist