Provider Demographics
NPI:1366816704
Name:RUSSO, REBECCA (LISW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 OLD LANE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1728
Mailing Address - Country:US
Mailing Address - Phone:937-321-6192
Mailing Address - Fax:
Practice Address - Street 1:2261 PHILADELPHIA DRIVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406
Practice Address - Country:US
Practice Address - Phone:937-734-6763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI. 15012751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical