Provider Demographics
NPI:1184993560
Name:RUSSO, ANGELA (LMHC, CASAC-T)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LMHC, CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5110
Mailing Address - Country:US
Mailing Address - Phone:718-948-3232
Mailing Address - Fax:
Practice Address - Street 1:3911 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5110
Practice Address - Country:US
Practice Address - Phone:718-948-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26780101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)