Provider Demographics
NPI:1598088197
Name:RUSSO, CAROLYN A (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 NW 201ST ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-2012
Mailing Address - Country:US
Mailing Address - Phone:206-658-3920
Mailing Address - Fax:
Practice Address - Street 1:200 1ST AVE W
Practice Address - Street 2:SUITE 400
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98119-4298
Practice Address - Country:US
Practice Address - Phone:206-658-3920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60320548101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health