Healthcare Provider Details

I. General information

NPI: 1982512349
Provider Name (Legal Business Name): KYLE JACK RUSSO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4375 FOOTHILL RD
PLEASANTON CA
94588-9720
US

IV. Provider business mailing address

4375 FOOTHILL RD
PLEASANTON CA
94588-9720
US

V. Phone/Fax

Practice location:
  • Phone: 925-461-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: