Provider Demographics
NPI:1770828469
Name:RUSSO, ANGELA (LCPC, CADC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 DEVELOPMENT DR
Mailing Address - Street 2:
Mailing Address - City:LIMESTONE
Mailing Address - State:ME
Mailing Address - Zip Code:04750-6128
Mailing Address - Country:US
Mailing Address - Phone:303-520-4618
Mailing Address - Fax:
Practice Address - Street 1:14 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARS HILL
Practice Address - State:ME
Practice Address - Zip Code:04758
Practice Address - Country:US
Practice Address - Phone:207-425-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC4911101YA0400X
MEXL3802101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME101Y00000XMedicare Oscar/Certification