Provider Demographics
NPI:1093459307
Name:RUSSO, DAN (MA/MA)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MA/MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 ROWELL CT
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3126
Mailing Address - Country:US
Mailing Address - Phone:202-630-1239
Mailing Address - Fax:
Practice Address - Street 1:113 ROWELL CT
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3126
Practice Address - Country:US
Practice Address - Phone:202-630-1239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704014718101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health