Provider Demographics
NPI:1043954373
Name:RUSSO, SARA LIDA NUSBAUM (LCSW)
Entity Type:Individual
Prefix:
First Name:SARA LIDA
Middle Name:NUSBAUM
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:LIDA
Other - Last Name:NUSBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:200 172ND ST APT 419
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3493
Mailing Address - Country:US
Mailing Address - Phone:305-606-5881
Mailing Address - Fax:
Practice Address - Street 1:200 172ND ST APT 419
Practice Address - Street 2:
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-3493
Practice Address - Country:US
Practice Address - Phone:305-606-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW224781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical