Provider Demographics
NPI:1568805620
Name:RUSSO, PAUL (MSED)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HANOVER PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5839
Mailing Address - Country:US
Mailing Address - Phone:347-916-0333
Mailing Address - Fax:718-246-1481
Practice Address - Street 1:15 HANOVER PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5839
Practice Address - Country:US
Practice Address - Phone:347-916-0333
Practice Address - Fax:718-246-1481
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool