Healthcare Provider Details

I. General information

NPI: 1982970935
Provider Name (Legal Business Name): MARY M RUSSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 MAGNOLIA ST
HOUMA LA
70360-6304
US

IV. Provider business mailing address

PO BOX 165
HOUMA LA
70361-0165
US

V. Phone/Fax

Practice location:
  • Phone: 985-879-3966
  • Fax:
Mailing address:
  • Phone: 985-879-3966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: