Provider Demographics
NPI:1114334851
Name:RUSSO, DANIELLE M (PSYD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:M
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 GRAND ST FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-4800
Mailing Address - Country:US
Mailing Address - Phone:212-420-1970
Mailing Address - Fax:212-420-1906
Practice Address - Street 1:465 GRAND ST FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4800
Practice Address - Country:US
Practice Address - Phone:212-420-1970
Practice Address - Fax:212-420-1906
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY203368734OtherPLACE OF EMPLOYMENT