MEDICARE: KAREN RUSSO PHD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	B1-0000259	DE

General Provider Information

NPI Number	:	1104188762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAREN RUSSO PHD LLC

Provider Business Mailing Address
First Line	:	500 CREEK VIEW RD
Second Line	:	SUITE 109
City	:	NEWARK
State	:	DE
Zip	:	19711-8549
Country	:	US
Telephone Number	:	302-738-3140
Fax Number	:	302-454-8026

Provider Business Practice Location Address
First Line	:	500 CREEK VIEW RD
Second Line	:	SUITE 109
City	:	NEWARK
State	:	DE
Zip	:	19711-8549
Country	:	US
Telephone Number	:	302-738-3140
Fax Number	:	302-454-8026

Authorized Official
Title or Position	:	OWNER, PSYCHOLOGIST
Name	:	KAREN RUSSO
Credential	:	PHD
Telephone Number	:	302-738-3140

Provider Enumeration Date	:	06/11/2012
Last Update Date	:	04/01/2015

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