Provider Demographics
NPI:1073730651
Name:RUSSO, MARYBETH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARYBETH
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9975 HILLSIDE TERRACE
Mailing Address - Street 2:
Mailing Address - City:MARCY
Mailing Address - State:NY
Mailing Address - Zip Code:13403
Mailing Address - Country:US
Mailing Address - Phone:315-797-4969
Mailing Address - Fax:
Practice Address - Street 1:9975 HILLSIDE TERRACE
Practice Address - Street 2:
Practice Address - City:MARCY
Practice Address - State:NY
Practice Address - Zip Code:13403
Practice Address - Country:US
Practice Address - Phone:315-797-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO 37233-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRO37233-1Medicaid
NYRO37233-1Medicare ID - Type UnspecifiedLICENSED CLINICAL SW