Provider Demographics
NPI:1447430004
Name:RUSSO, INGRID ANGELA (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:INGRID
Middle Name:ANGELA
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 WESTON RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-5333
Mailing Address - Country:US
Mailing Address - Phone:325-224-0534
Mailing Address - Fax:325-617-2497
Practice Address - Street 1:2137 OFFICE PARK DR
Practice Address - Street 2:SUITE F
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6893
Practice Address - Country:US
Practice Address - Phone:325-944-3330
Practice Address - Fax:325-617-2497
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-11
Last Update Date:2009-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX502421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX613665Medicare PIN