Provider Demographics
NPI:1518318153
Name:RUSSO, SALVATORE (LPC)
Entity Type:Individual
Prefix:
First Name:SALVATORE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11270 E 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2599
Mailing Address - Country:US
Mailing Address - Phone:586-738-9320
Mailing Address - Fax:586-751-3201
Practice Address - Street 1:11270 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2599
Practice Address - Country:US
Practice Address - Phone:586-738-9320
Practice Address - Fax:586-751-3201
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015475101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor