Provider Demographics
NPI:1821144288
Name:RUSSO, FRED CIPRIANO (LCSW)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:CIPRIANO
Last Name:RUSSO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 PULASKI ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731
Mailing Address - Country:US
Mailing Address - Phone:631-261-4296
Mailing Address - Fax:631-261-4296
Practice Address - Street 1:1023 PULASKI ROAD
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731
Practice Address - Country:US
Practice Address - Phone:631-261-4296
Practice Address - Fax:631-261-4296
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0234241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01968423Medicaid
NY118060OtherVALUE OPTIONS
NY7400383OtherGHI
NY118060OtherVALUE OPTIONS