Provider Demographics
NPI:1780753277
Name:RUSSO, DEBORAH ANNE (PSYD)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:ANNE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 BAYFORD CT SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-4198
Mailing Address - Country:US
Mailing Address - Phone:770-568-0453
Mailing Address - Fax:
Practice Address - Street 1:6065 LAKE FORREST DR STE 250
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3868
Practice Address - Country:US
Practice Address - Phone:770-568-0453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002379103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical