Provider Demographics
NPI:1235412107
Name:RUSSO, CHRISTOPHER J (LICSW)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 PAVILION AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-1534
Mailing Address - Country:US
Mailing Address - Phone:401-490-8900
Mailing Address - Fax:401-490-2619
Practice Address - Street 1:49 PAVILION AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-1534
Practice Address - Country:US
Practice Address - Phone:401-490-8900
Practice Address - Fax:401-490-2619
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW014001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical