Provider Demographics
NPI:1366039182
Name:RUSSO, STEPHANIE CAROLINE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CAROLINE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 1/2 COTTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-1925
Mailing Address - Country:US
Mailing Address - Phone:203-906-0400
Mailing Address - Fax:
Practice Address - Street 1:435 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-1964
Practice Address - Country:US
Practice Address - Phone:203-736-2601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker