Provider Demographics
NPI:1558490466
Name:RUSSO, MARIA THERESA (PHD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:THERESA
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4062
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-0254
Mailing Address - Country:US
Mailing Address - Phone:631-329-3185
Mailing Address - Fax:631-907-0726
Practice Address - Street 1:7 WILDFLOWER LANE
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-0254
Practice Address - Country:US
Practice Address - Phone:631-329-3185
Practice Address - Fax:631-907-0726
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010078103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV62242Medicare ID - Type UnspecifiedLICENSED PSYCHOLOGIST