Healthcare Provider Details

I. General information

NPI: 1861328262
Provider Name (Legal Business Name): ANGELA MARIE RUSSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22672 LAMBERT ST STE 611
LAKE FOREST CA
92630-1613
US

IV. Provider business mailing address

22672 LAMBERT ST STE 611
LAKE FOREST CA
92630-1613
US

V. Phone/Fax

Practice location:
  • Phone: 949-329-8161
  • Fax:
Mailing address:
  • Phone: 949-329-8161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT29190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: