Provider Demographics
NPI:1194809038
Name:RUSSO, GAIL (LCSW)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 TIMOTHY RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-4517
Mailing Address - Country:US
Mailing Address - Phone:518-573-1345
Mailing Address - Fax:
Practice Address - Street 1:4 TIMOTHY RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-4517
Practice Address - Country:US
Practice Address - Phone:518-573-1345
Practice Address - Fax:973-406-7396
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC062530001041C0700X
NYR0162541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA8010Medicare ID - Type Unspecified
NY53033BMedicare UPIN