Provider Demographics
NPI:1679852834
Name:RUSSO, CAROL ANNE (LMHC NCC)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANNE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LMHC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 SW 38TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-4893
Mailing Address - Country:US
Mailing Address - Phone:239-772-5091
Mailing Address - Fax:
Practice Address - Street 1:4818 CORONADO PKWY
Practice Address - Street 2:SUITE 3
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-9592
Practice Address - Country:US
Practice Address - Phone:239-772-5091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 10590101YP2500X
NJ37PC00018400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional