Provider Demographics
NPI:1770835399
Name:RUSSO-GARCIA, KATHLEEN A (LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:RUSSO-GARCIA
Suffix:
Gender:F
Credentials:LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5407 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-2024
Mailing Address - Country:US
Mailing Address - Phone:410-433-8861
Mailing Address - Fax:410-433-1249
Practice Address - Street 1:5407 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2024
Practice Address - Country:US
Practice Address - Phone:410-433-8861
Practice Address - Fax:410-433-1249
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC00886101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional