Provider Demographics
NPI:1609926914
Name:RUSSO-SMITH, ANGELA (MA)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:RUSSO-SMITH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 DENISE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-4010
Mailing Address - Country:US
Mailing Address - Phone:631-321-4929
Mailing Address - Fax:
Practice Address - Street 1:1441 OLD NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-2146
Practice Address - Country:US
Practice Address - Phone:516-625-6846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities