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NPI Code Detail

MEDICARE: MRS. ROBERTA RUSSO CSW008127

MEDICARE: MRS. ROBERTA RUSSO CSW008127
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
11041C0700XClinical Social WorkerCSW008127GA

General Provider Information

NPI Number : 1902572688
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. ROBERTA RUSSO CSW008127
Provider Business Mailing Address
First Line : 742 FIRST COTTON DR
Second Line :
City : POWDER SPRINGS
State : GA
Zip : 30127-6237
Country : US
Telephone Number : 404-396-4761
Fax Number :
Provider Business Practice Location Address
First Line : 3911 MARY ELIZA TRCE NW STE 200
Second Line :
City : MARIETTA
State : GA
Zip : 30064-1088
Country : US
Telephone Number : 678-631-9907
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/21/2021
Last Update Date : 07/01/2022

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