Provider Demographics
NPI:1750407664
Name:RUSSO, JOSEPH ANTHONY (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:25 CANTERBURY RD
Mailing Address - Street 2:SUITE #308
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-3403
Mailing Address - Country:US
Mailing Address - Phone:585-506-6096
Mailing Address - Fax:585-442-5971
Practice Address - Street 1:25 CANTERBURY RD
Practice Address - Street 2:SUITE #308
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-3403
Practice Address - Country:US
Practice Address - Phone:585-506-6096
Practice Address - Fax:585-442-5971
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY012173103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY183488FCOtherPREFERRED CARE