Provider Demographics
NPI:1902041825
Name:RUSSO, STEPHEN A (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-0741
Mailing Address - Country:US
Mailing Address - Phone:484-818-2225
Mailing Address - Fax:866-818-4032
Practice Address - Street 1:3300 TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-1925
Practice Address - Country:US
Practice Address - Phone:484-818-2225
Practice Address - Fax:866-818-4032
Is Sole Proprietor?:No
Enumeration Date:2008-12-05
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015087103TE1100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports