Provider Demographics
NPI:1619066933
Name:RUSSOTTO, JOHN (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RUSSOTTO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 LA PUERTA DEL SOL BLVD S APT 234
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33715-1426
Mailing Address - Country:US
Mailing Address - Phone:727-710-5487
Mailing Address - Fax:
Practice Address - Street 1:1616 18TH ST NW STE 111
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-2521
Practice Address - Country:US
Practice Address - Phone:202-249-1163
Practice Address - Fax:703-658-9306
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL179331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC950814Medicare PIN