Healthcare Provider Details

I. General information

NPI: 1225190549
Provider Name (Legal Business Name): ANGEL M. RUSSO, PH.D., PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 MAIN ST #400
WILLIAMSVILLE NY
14221-5776
US

IV. Provider business mailing address

5820 MAIN ST 400
WILLIAMSVILLE NY
14221-5776
US

V. Phone/Fax

Practice location:
  • Phone: 716-667-7031
  • Fax: 716-667-7034
Mailing address:
  • Phone: 716-667-7031
  • Fax: 716-667-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ANGEL M. RUSSO
Title or Position: DR.
Credential: PH.D.
Phone: 716-667-7031