Provider Demographics
NPI:1194257659
Name:RUSO, PHYLICIA
Entity type:Individual
Prefix:
First Name:PHYLICIA
Middle Name:
Last Name:RUSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18064 KARLIN RD
Mailing Address - Street 2:
Mailing Address - City:THOMPSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49683-9766
Mailing Address - Country:US
Mailing Address - Phone:269-271-1045
Mailing Address - Fax:
Practice Address - Street 1:18064 KARLIN RD
Practice Address - Street 2:
Practice Address - City:THOMPSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49683-9766
Practice Address - Country:US
Practice Address - Phone:269-271-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst