Provider Demographics
NPI:1619012481
Name:RUSSO, GERALDINE (LCSW CASAC)
Entity Type:Individual
Prefix:MS
First Name:GERALDINE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LCSW CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 W 24TH ST #16H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011
Mailing Address - Country:US
Mailing Address - Phone:212-679-6007
Mailing Address - Fax:
Practice Address - Street 1:150 BROADWAY
Practice Address - Street 2:SUITE 1208
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038
Practice Address - Country:US
Practice Address - Phone:212-679-6007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR04283411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN7B552Medicare ID - Type Unspecified