Provider Demographics
NPI:1518466242
Name:RUSSO, ANGELICA RENEE (LPC)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:RENEE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LINDSLEY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07960-4456
Mailing Address - Country:US
Mailing Address - Phone:973-998-7900
Mailing Address - Fax:973-998-7910
Practice Address - Street 1:25 LINDSLEY DR STE 300
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-4456
Practice Address - Country:US
Practice Address - Phone:973-998-7900
Practice Address - Fax:973-998-7910
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00613500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1881936847OtherNPI