Provider Demographics
NPI:1598156929
Name:RUSSO, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:RUSSO
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 1:4725 PEACHTREE CORNERS CIR
Mailing Address - Street 2:SUITE 385
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2571
Mailing Address - Country:US
Mailing Address - Phone:770-676-7748
Mailing Address - Fax:
Practice Address - Street 1:4725 PEACHTREE CORNERS CIR
Practice Address - Street 2:SUITE 385
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-2571
Practice Address - Country:US
Practice Address - Phone:770-676-7748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003761101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health