MEDICARE: MELISSA RUSSO LICSW

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	1041C0700X	Clinical Social Worker	115036	MA

General Provider Information

NPI Number	:	1992032783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA RUSSO LICSW

Provider Business Mailing Address
First Line	:	150 S HUNTINGTON AVE
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02130-4893
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 S HUNTINGTON AVE
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02130-4893
Country	:	US
Telephone Number	:	617-232-9500
Fax Number	:

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

Provider Enumeration Date	:	11/16/2009
Last Update Date	:	05/18/2023

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