Provider Demographics
NPI:1417346537
Name:RUSSELL-IRACE, MINETTE (PSYD)
Entity Type:Individual
Prefix:
First Name:MINETTE
Middle Name:
Last Name:RUSSELL-IRACE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 CLIFTON PL
Mailing Address - Street 2:SUITE 10
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-5181
Mailing Address - Country:US
Mailing Address - Phone:845-272-2118
Mailing Address - Fax:
Practice Address - Street 1:203 CLIFTON PL
Practice Address - Street 2:SUITE 10
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-5181
Practice Address - Country:US
Practice Address - Phone:845-272-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021071103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program