Provider Demographics
NPI:1760945463
Name:RUSSOTTI, JUSTIN (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:RUSSOTTI
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 TROY RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2943
Mailing Address - Country:US
Mailing Address - Phone:585-281-4441
Mailing Address - Fax:
Practice Address - Street 1:95 ALLENS CREEK RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3250
Practice Address - Country:US
Practice Address - Phone:585-281-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0873931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical