Provider Demographics
NPI:1689880619
Name:RUSSO, MARY (PHD, MFT)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 E HAMILTON AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-0244
Mailing Address - Country:US
Mailing Address - Phone:408-920-1992
Mailing Address - Fax:
Practice Address - Street 1:137 E HAMILTON AVE STE 207
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0244
Practice Address - Country:US
Practice Address - Phone:408-920-1992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28070106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist