Healthcare Provider Details

I. General information

NPI: 1538292982
Provider Name (Legal Business Name): SUSAN K RUSSO L.P.C.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 STATE RD. 522 #6
EL PRADO NM
87529
US

IV. Provider business mailing address

HC 74 BOX 22615
EL PRADO NM
87529-9526
US

V. Phone/Fax

Practice location:
  • Phone: 505-737-9151
  • Fax: 505-751-0846
Mailing address:
  • Phone: 505-776-3826
  • Fax: 505-751-0846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0088901
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: