Provider Demographics
NPI:1609867670
Name:DELLO RUSSO, ROBERT GERARD (PHD, LADC I)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GERARD
Last Name:DELLO RUSSO
Suffix:
Gender:M
Credentials:PHD, LADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-6103
Mailing Address - Country:US
Mailing Address - Phone:617-484-4146
Mailing Address - Fax:
Practice Address - Street 1:109 WARREN AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-6103
Practice Address - Country:US
Practice Address - Phone:617-484-4146
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
MA2943103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAR84937Medicare UPIN
MADEW03063Medicare ID - Type Unspecified