Provider Demographics
NPI:1962063560
Name:RUSSO, HARRY
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11329 GRANDVILLE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2383
Mailing Address - Country:US
Mailing Address - Phone:863-559-7617
Mailing Address - Fax:
Practice Address - Street 1:8950 MARTIN LUTHER KING ST N STE 190
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-3001
Practice Address - Country:US
Practice Address - Phone:727-576-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician