Provider Demographics
NPI:1366217846
Name:RUSSO, BERNADETTE (LMHC)
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 WICKLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1334
Mailing Address - Country:US
Mailing Address - Phone:740-412-6768
Mailing Address - Fax:
Practice Address - Street 1:9210 ESTERO PARK COMMONS BLVD STE 7
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-6395
Practice Address - Country:US
Practice Address - Phone:740-412-6768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH20815101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health