Provider Demographics
NPI:1427669399
Name:RUSSO, RENEE MARILYN (LCSW)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:MARILYN
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 1:3328 2ND ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5214
Mailing Address - Country:US
Mailing Address - Phone:516-761-0076
Mailing Address - Fax:
Practice Address - Street 1:3328 2ND ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5214
Practice Address - Country:US
Practice Address - Phone:516-761-0076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108761-01104100000X
NY098571-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker