Provider Demographics
NPI:1932314226
Name:RUSSO, MARYANN (MARYANN RUSSO LMFT)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MARYANN RUSSO LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 ESPLANADE #4
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277
Mailing Address - Country:US
Mailing Address - Phone:310-944-3259
Mailing Address - Fax:
Practice Address - Street 1:1840 S. ELENA ANE.
Practice Address - Street 2:SUITE 207
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277
Practice Address - Country:US
Practice Address - Phone:310-534-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT34309106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist