Provider Demographics
NPI:1710353370
Name:RUSSO, ANDRES SR
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:RUSSO
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-5042
Mailing Address - Country:US
Mailing Address - Phone:978-382-0522
Mailing Address - Fax:
Practice Address - Street 1:12 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-5042
Practice Address - Country:US
Practice Address - Phone:978-382-0522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health