1447430004 NPI number — MRS. INGRID ANGELA RUSSO MSW, LCSW

Table of content: MRS. INGRID ANGELA RUSSO MSW, LCSW (NPI 1447430004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447430004 NPI number — MRS. INGRID ANGELA RUSSO MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSO
Provider First Name:
INGRID
Provider Middle Name:
ANGELA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447430004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1705 WESTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANGELO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76901-5333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-224-0534
Provider Business Mailing Address Fax Number:
325-617-2497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2137 OFFICE PARK DR
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
SAN ANGELO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76904-6893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-944-3330
Provider Business Practice Location Address Fax Number:
325-617-2497
Provider Enumeration Date:
11/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  50242 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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