Provider Demographics
NPI:1740899665
Name:RUSSO, KEVIN (BCBA, LABA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 MAIN ST # 269
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-0616
Mailing Address - Country:US
Mailing Address - Phone:617-797-5511
Mailing Address - Fax:
Practice Address - Street 1:564 MAIN ST STE 209
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-5568
Practice Address - Country:US
Practice Address - Phone:781-736-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA155103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst