Provider Demographics
NPI:1629197546
Name:RUSSO, DEBORAH J (PHD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:ECU PHYSICIANS
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 JOHNS HOPKINS DR
Practice Address - Street 2:ECU PHYSICIANS PSYCHIATRIC MEDICINE OUTPATIENT CENTER
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7225
Practice Address - Country:US
Practice Address - Phone:252-744-1406
Practice Address - Fax:252-744-2419
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3986103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC162G7OtherBCBSNC
NC6001277Medicaid
NC2826120Medicare PIN
NC6001277Medicaid