Individual
MARY RUSSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
925 ROUTE 73 N STE H, MARLTON, NJ 08053-1277
(609) 713-8763
Mailing address
925 ROUTE 73 N STE H, MARLTON, NJ 08053-1277
(609) 713-8763
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
R94585277161805
DRIVER LICENSE
NJ
Enumeration date
06/01/2022
Last updated
06/01/2022
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