Provider Demographics
NPI:1245004910
Name:BLACKSTONE, RUSS
Entity type:Individual
Prefix:
First Name:RUSS
Middle Name:
Last Name:BLACKSTONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RUSSELL
Other - Middle Name:H
Other - Last Name:BLACKSTONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:1515 KENSINGTON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1436
Mailing Address - Country:US
Mailing Address - Phone:716-697-7380
Mailing Address - Fax:
Practice Address - Street 1:1515 KENSINGTON AVE STE 103
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1436
Practice Address - Country:US
Practice Address - Phone:716-697-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014673101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health