Provider Demographics
NPI:1811958861
Name:RUSSO, THOMAS P (PHD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:P
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N GREENE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1524
Mailing Address - Country:US
Mailing Address - Phone:410-605-7404
Mailing Address - Fax:410-605-7931
Practice Address - Street 1:10 N GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-605-7404
Practice Address - Fax:410-605-7931
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02431103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical