Provider Demographics
NPI:1265034334
Name:RUSSO, AMY L (AMFT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:RUSSO
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16398 ANACONDA RD
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8214
Mailing Address - Country:US
Mailing Address - Phone:559-975-9131
Mailing Address - Fax:
Practice Address - Street 1:3636 N 1ST ST STE 135&154
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6800
Practice Address - Country:US
Practice Address - Phone:559-225-1464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122974106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist