Provider Demographics
NPI:1669206843
Name:RUSSOM, MARGO
Entity type:Individual
Prefix:
First Name:MARGO
Middle Name:
Last Name:RUSSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 BROOKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-3618
Mailing Address - Country:US
Mailing Address - Phone:518-210-2034
Mailing Address - Fax:
Practice Address - Street 1:2 BETHLEHEM CT
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1306
Practice Address - Country:US
Practice Address - Phone:518-478-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
NY$$$$$$$$$103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool