Provider Demographics
NPI:1225037575
Name:RUSSO, JOAN CAROL (PHD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:CAROL
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:W340N6509 BREEZY POINT RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-5132
Mailing Address - Country:US
Mailing Address - Phone:262-490-9114
Mailing Address - Fax:
Practice Address - Street 1:W340N6509 BREEZY POINT RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-5132
Practice Address - Country:US
Practice Address - Phone:262-490-9114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1169103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39114000Medicaid
WI39114000Medicaid
WIR78219Medicare UPIN