Provider Demographics
NPI:1225190549
Name:ANGEL M. RUSSO, PH.D., PLLC
Entity Type:Organization
Organization Name:ANGEL M. RUSSO, PH.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:716-667-7031
Mailing Address - Street 1:5820 MAIN ST
Mailing Address - Street 2:400
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5776
Mailing Address - Country:US
Mailing Address - Phone:716-667-7031
Mailing Address - Fax:716-667-7034
Practice Address - Street 1:5820 MAIN ST
Practice Address - Street 2:#400
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5776
Practice Address - Country:US
Practice Address - Phone:716-667-7031
Practice Address - Fax:716-667-7034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty