Provider Demographics
NPI:1962997155
Name:LO RUSSO, STEPHANY (MSED, BCBA)
Entity type:Individual
Prefix:
First Name:STEPHANY
Middle Name:
Last Name:LO RUSSO
Suffix:
Gender:F
Credentials:MSED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1492 BELLMORE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-3713
Mailing Address - Country:US
Mailing Address - Phone:516-348-4487
Mailing Address - Fax:
Practice Address - Street 1:MANHATTAN BEHAVIORAL CENTER
Practice Address - Street 2:124 W 95TH STREET
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025
Practice Address - Country:US
Practice Address - Phone:646-480-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-18-29784103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst