Provider Demographics
NPI:1952843674
Name:RUSSO, STEPHANIE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 PRAIRIE ELM DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-4211
Mailing Address - Country:US
Mailing Address - Phone:785-764-3053
Mailing Address - Fax:
Practice Address - Street 1:1715 E CEDAR ST STE 115
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1791
Practice Address - Country:US
Practice Address - Phone:785-764-3053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS8795104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker