Healthcare Provider Details

I. General information

NPI: 1902041825
Provider Name (Legal Business Name): STEPHEN A. RUSSO PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 02/08/2020
Certification Date: 02/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 TOWNSHIP LINE RD
DREXEL HILL PA
19026-1925
US

IV. Provider business mailing address

PO BOX 741
MEDIA PA
19063-0741
US

V. Phone/Fax

Practice location:
  • Phone: 484-818-2225
  • Fax: 866-818-4032
Mailing address:
  • Phone: 484-818-2225
  • Fax: 866-818-4032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS015087
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License NumberPS015087
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: