Provider Demographics
NPI:1104374776
Name:RUSSO, RENEE NICOLE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:NICOLE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:MI
Mailing Address - Zip Code:49074-0334
Mailing Address - Country:US
Mailing Address - Phone:269-224-2339
Mailing Address - Fax:
Practice Address - Street 1:5360 HOLIDAY TER STE 16A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2126
Practice Address - Country:US
Practice Address - Phone:269-224-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional