MEDICARE: MRS. CAROL ANNE RUSSO LMHC NCC

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	101YP2500X	Professional Counselor	MH 10590	FL
2	101YP2500X	Professional Counselor	37PC00018400	NJ

General Provider Information

NPI Number	:	1679852834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL ANNE RUSSO LMHC NCC

Provider Business Mailing Address
First Line	:	2721 SW 38TH ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33914-4893
Country	:	US
Telephone Number	:	239-772-5091
Fax Number	:

Provider Business Practice Location Address
First Line	:	4818 CORONADO PKWY
Second Line	:	SUITE 3
City	:	CAPE CORAL
State	:	FL
Zip	:	33904-9592
Country	:	US
Telephone Number	:	239-772-5091
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2011
Last Update Date	:	08/05/2011

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