Individual
KELLIE MARIE RUSSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CASAC-2
Contact information
Practice address
460 BRIELLE AVE, STATEN ISLAND, NY 10314-6427
(718) 412-3156
(718) 356-3155
Mailing address
460 BRIELLE AVE, STATEN ISLAND, NY 10314-6427
(718) 412-3156
(718) 356-3155
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
29679
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
29679
CASAC
NY
Enumeration date
05/08/2019
Last updated
05/08/2019
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