Provider Demographics
NPI:1457376543
Name:RUSSO, ANGEL M (PHD)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:M
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6541 WEBSTER RD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1920
Mailing Address - Country:US
Mailing Address - Phone:716-667-7031
Mailing Address - Fax:716-667-7034
Practice Address - Street 1:6541 WEBSTER RD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1920
Practice Address - Country:US
Practice Address - Phone:716-667-7031
Practice Address - Fax:716-667-7034
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11656-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000511671007OtherBLUE CROSS & BLUE SHIELD
NM6105576OtherINDEPENDENT HEALTH
NY00020246901OtherUNIVERA
NY000511671007OtherBLUE CROSS & BLUE SHIELD