=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457722464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEIRDRE LEE RUSSO MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2015
-----------------------------------------------------
Last Update Date | 10/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 S JERSEY AVE SUITE 42
-----------------------------------------------------
City | EAST SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-689-1728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 WINMAR LN
-----------------------------------------------------
City | SAYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11782-1371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-404-6431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | P97555
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------