Provider Demographics
NPI:1053841858
Name:RUSSO, ANGELA MARIE (BCBA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10442 YOLANDA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3440
Mailing Address - Country:US
Mailing Address - Phone:818-606-3754
Mailing Address - Fax:
Practice Address - Street 1:801 CORPORATE CENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2627
Practice Address - Country:US
Practice Address - Phone:909-618-0974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-16-24693103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty