Provider Demographics
NPI:1093129744
Name:RUSSO, DEBORAH J (LCSW)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
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 1:55 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-3395
Mailing Address - Country:US
Mailing Address - Phone:208-794-9367
Mailing Address - Fax:
Practice Address - Street 1:814 N 8TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5521
Practice Address - Country:US
Practice Address - Phone:208-242-2701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID338421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical