Provider Demographics
NPI:1568070316
Name:RUSSELL, STEPHANIE MICHELLE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 5TH AVE # 3F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-8136
Mailing Address - Country:US
Mailing Address - Phone:303-505-1790
Mailing Address - Fax:
Practice Address - Street 1:1211 STEWART AVE STE 100
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-1601
Practice Address - Country:US
Practice Address - Phone:399-851-6465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009894101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health