Individual
KEVIN RUSSO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
BCBA, LABA
Contact information
Practice address
564 MAIN ST STE 209, WALTHAM, MA 02452-5568
(781) 736-7900
Mailing address
738 MAIN ST # 269, WALTHAM, MA 02451-0616
(617) 797-5511
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
155
MA
Other
Enumeration date
07/27/2020
Last updated
07/27/2020
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