Provider Demographics
NPI:1821428616
Name:RUSSO, M. KATHLEEN (LADC)
Entity Type:Individual
Prefix:
First Name:M. KATHLEEN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 W MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:TILTON
Mailing Address - State:NH
Mailing Address - Zip Code:03276-5048
Mailing Address - Country:US
Mailing Address - Phone:603-860-1319
Mailing Address - Fax:603-671-7361
Practice Address - Street 1:322 W MAIN ST STE 101
Practice Address - Street 2:RIVERFRONT PLACE
Practice Address - City:TILTON
Practice Address - State:NH
Practice Address - Zip Code:03276-5048
Practice Address - Country:US
Practice Address - Phone:603-860-1319
Practice Address - Fax:603-671-7361
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0445101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)