Provider Demographics
NPI:1417343138
Name:RUSSO, BRYAN (MS)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31822 VILLAGE CENTER ROAD, SUITE 102
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361
Mailing Address - Country:US
Mailing Address - Phone:805-870-5804
Mailing Address - Fax:
Practice Address - Street 1:31822 VILLAGE CENTER ROAD, SUITE 102
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361
Practice Address - Country:US
Practice Address - Phone:805-870-5804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist