Provider Demographics
NPI:1912274937
Name:VERSOLA-RUSSO, JUDY M (PSYD)
Entity type:Individual
Prefix:DR
First Name:JUDY
Middle Name:M
Last Name:VERSOLA-RUSSO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JUDY
Other - Middle Name:M
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:29635 FERRY POINT DR
Mailing Address - Street 2:
Mailing Address - City:TRAPPE
Mailing Address - State:MD
Mailing Address - Zip Code:21673-1621
Mailing Address - Country:US
Mailing Address - Phone:410-725-4884
Mailing Address - Fax:
Practice Address - Street 1:29635 FERRY POINT DR
Practice Address - Street 2:
Practice Address - City:TRAPPE
Practice Address - State:MD
Practice Address - Zip Code:21673-1621
Practice Address - Country:US
Practice Address - Phone:410-725-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04931103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical