MEDICARE: MS. STEPHANIE RUSSO LMSW

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	104100000X	Social Worker	8795	KS

General Provider Information

NPI Number	:	1952843674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STEPHANIE RUSSO LMSW

Provider Business Mailing Address
First Line	:	2631 PRAIRIE ELM DR
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66047-4211
Country	:	US
Telephone Number	:	785-764-3053
Fax Number	:

Provider Business Practice Location Address
First Line	:	1715 E CEDAR ST STE 115
Second Line	:
City	:	OLATHE
State	:	KS
Zip	:	66062-1791
Country	:	US
Telephone Number	:	785-764-3053
Fax Number	:

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

Provider Enumeration Date	:	11/11/2016
Last Update Date	:	11/11/2016

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