Provider Demographics
NPI:1871605113
Name:RUSSO, DAVID PATRICK (MA, LMFT, LMHC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:PATRICK
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MA, LMFT, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:MA
Mailing Address - Zip Code:01522-1413
Mailing Address - Country:US
Mailing Address - Phone:508-366-4000
Mailing Address - Fax:508-870-9991
Practice Address - Street 1:800 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MA
Practice Address - Zip Code:01520-1838
Practice Address - Country:US
Practice Address - Phone:508-829-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA887106H00000X
MA3364101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist