Provider Demographics
NPI:1326313487
Name:RUSSO, TANYA (PCC)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3722 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2934
Mailing Address - Country:US
Mailing Address - Phone:330-492-2006
Mailing Address - Fax:330-492-2161
Practice Address - Street 1:3722 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2934
Practice Address - Country:US
Practice Address - Phone:330-492-2006
Practice Address - Fax:330-492-2161
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE/0001055-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional