Provider Demographics
NPI:1700975208
Name:RUSSOMANNO, JULIA (MC, LPC)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:RUSSOMANNO
Suffix:
Gender:F
Credentials:MC, LPC
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:
Other - Last Name:BUNKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1093 W GLENMERE DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-7581
Mailing Address - Country:US
Mailing Address - Phone:602-750-4018
Mailing Address - Fax:
Practice Address - Street 1:1351 N ALMA SCHOOL RD
Practice Address - Street 2:205
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5936
Practice Address - Country:US
Practice Address - Phone:480-491-7048
Practice Address - Fax:480-963-2036
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-10273101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional