Provider Demographics
NPI:1588068423
Name:RUSSO, KRISTIN
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:RUSSO
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 1:75 1/2 PICKERING ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2018
Mailing Address - Country:US
Mailing Address - Phone:978-766-9111
Mailing Address - Fax:
Practice Address - Street 1:75 1/2 PICKERING ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2018
Practice Address - Country:US
Practice Address - Phone:978-766-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNMDCXZ7871625OtherBLUECROSS BLUESHIELD