Provider Demographics
NPI:1477022333
Name:RUSSO, JAMES MICHAEL
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:RUSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12039 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3042
Mailing Address - Country:US
Mailing Address - Phone:443-881-2024
Mailing Address - Fax:410-833-4102
Practice Address - Street 1:12039 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-3042
Practice Address - Country:US
Practice Address - Phone:443-881-2024
Practice Address - Fax:410-833-4102
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD056201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical