Provider Demographics
NPI:1174869127
Name:NGUYEN RUSSO, LAURA GT (LMFT102780)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:GT
Last Name:NGUYEN RUSSO
Suffix:
Gender:F
Credentials:LMFT102780
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12816 INGLEWOOD AVE # 73
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5118
Mailing Address - Country:US
Mailing Address - Phone:949-229-0148
Mailing Address - Fax:
Practice Address - Street 1:12816 INGLEWOOD AVE # 73
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5118
Practice Address - Country:US
Practice Address - Phone:949-229-0148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF76963106H00000X
CALMFT102780106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist