Provider Demographics
NPI:1013054741
Name:RUSSUM, ANN SARENE
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:SARENE
Last Name:RUSSUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARENE
Other - Middle Name:
Other - Last Name:RUSSUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:3744 MT DIABLO BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3614
Mailing Address - Country:US
Mailing Address - Phone:925-788-7599
Mailing Address - Fax:
Practice Address - Street 1:3744 MT DIABLO BLVD STE 206
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3614
Practice Address - Country:US
Practice Address - Phone:925-788-7599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 50843106H00000X
CAMFC51246106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist