Provider Demographics
NPI:1922346014
Name:RUSSO, MARIE JOSEPHINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:JOSEPHINE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 GREGORY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4618
Mailing Address - Country:US
Mailing Address - Phone:973-572-6507
Mailing Address - Fax:
Practice Address - Street 1:246 EDISON & VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013
Practice Address - Country:US
Practice Address - Phone:973-572-6507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC047573001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical