Provider Demographics
NPI:1134304967
Name:RUSSO, MARY FRANCES (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:FRANCES
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 STATE ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1454
Mailing Address - Country:US
Mailing Address - Phone:814-480-8797
Mailing Address - Fax:814-459-2303
Practice Address - Street 1:100 STATE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1454
Practice Address - Country:US
Practice Address - Phone:814-480-8797
Practice Address - Fax:814-459-2303
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007343L103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent