Healthcare Provider Details

I. General information

NPI: 1548825151
Provider Name (Legal Business Name): KELLIE MARIE RUSSO CASAC-2
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BRIELLE AVE
STATEN ISLAND NY
10314-6427
US

IV. Provider business mailing address

460 BRIELLE AVE
STATEN ISLAND NY
10314-6427
US

V. Phone/Fax

Practice location:
  • Phone: 718-412-3156
  • Fax: 718-356-3155
Mailing address:
  • Phone: 718-412-3156
  • Fax: 718-356-3155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number29679
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: