Provider Demographics
NPI:1205109667
Name:GENA RUSSO
Entity type:Organization
Organization Name:GENA RUSSO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICSENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:GENA
Authorized Official - Middle Name:HOPE
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-874-7149
Mailing Address - Street 1:2984 S WABASH ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-4223
Mailing Address - Country:US
Mailing Address - Phone:860-874-7149
Mailing Address - Fax:
Practice Address - Street 1:2984 S WABASH ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-4223
Practice Address - Country:US
Practice Address - Phone:860-874-7149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1957251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health