Individual
JOAN CAROL RUSSO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
W340N6509 BREEZY POINT RD, OCONOMOWOC, WI 53066-5132
(262) 490-9114
Mailing address
W340N6509 BREEZY POINT RD, OCONOMOWOC, WI 53066-5132
(262) 490-9114
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
1169
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
39114000
—
WI
Enumeration date
07/19/2005
Last updated
07/07/2014
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