Provider Demographics
NPI:1346439742
Name:RUSSO, CAROL K (LMFT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:K
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 48TH AVE. NO.
Mailing Address - Street 2:PARKWAY OFFICE PLAZA SUITE 111-E
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5926
Mailing Address - Country:US
Mailing Address - Phone:843-254-9447
Mailing Address - Fax:843-449-8753
Practice Address - Street 1:1107 48TH AVE N
Practice Address - Street 2:SUITE 111-E
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5443
Practice Address - Country:US
Practice Address - Phone:843-254-9447
Practice Address - Fax:843-449-8753
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4054106H00000X
NC1120106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6105147Medicaid