Provider Demographics
NPI:1659096816
Name:RUSSO, KARA B (LAC)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:B
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LAC
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 2244
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-2244
Mailing Address - Country:US
Mailing Address - Phone:609-429-4451
Mailing Address - Fax:
Practice Address - Street 1:12 PRINCETON PINES PL
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3557
Practice Address - Country:US
Practice Address - Phone:732-233-2495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37A00400700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty