Individual
NICOLE RUSSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
9815 ROOSEVELT BLVD, PHILADELPHIA, PA 19114-1035
(616) 644-6464
Mailing address
680 AMERICAN AVE, KING OF PRUSSIA, PA 19406-4023
(616) 644-6464
(610) 981-6078
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Enumeration date
01/11/2018
Last updated
01/11/2018
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