Provider Demographics
NPI:1548825151
Name:RUSSO, KELLIE MARIE (CASAC-2)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CASAC-2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 BRIELLE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6427
Mailing Address - Country:US
Mailing Address - Phone:718-412-3156
Mailing Address - Fax:718-356-3155
Practice Address - Street 1:460 BRIELLE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6427
Practice Address - Country:US
Practice Address - Phone:718-412-3156
Practice Address - Fax:718-356-3155
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29679101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY29679OtherCASAC