Provider Demographics
NPI:1366658841
Name:RUSSO, GINA MARIE (SUDCC III-CS)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:SUDCC III-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 E COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1911
Mailing Address - Country:US
Mailing Address - Phone:949-402-9596
Mailing Address - Fax:
Practice Address - Street 1:218 E COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1911
Practice Address - Country:US
Practice Address - Phone:714-992-4770
Practice Address - Fax:714-992-5745
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8109101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA196711000Medicaid