Provider Demographics
NPI:1184924292
Name:RUSSO, KRISTINA LEA (MA LMHC)
Entity type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:LEA
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:MS
Other - First Name:KRISTINA
Other - Middle Name:LEA
Other - Last Name:KLAWITTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA LMHC
Mailing Address - Street 1:10 MEADOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7122
Mailing Address - Country:US
Mailing Address - Phone:508-742-4400
Mailing Address - Fax:508-408-6192
Practice Address - Street 1:10 MEADOWBROOK RD
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7122
Practice Address - Country:US
Practice Address - Phone:508-742-4400
Practice Address - Fax:508-408-6192
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5692101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional