Provider Demographics
NPI:1881691087
Name:RUSSO, NANCY (LMHC)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 KAY LARKIN DR
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-2307
Mailing Address - Country:US
Mailing Address - Phone:386-385-1243
Mailing Address - Fax:
Practice Address - Street 1:330 KAY LARKIN DR
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-2307
Practice Address - Country:US
Practice Address - Phone:386-385-1243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6919101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019791100Medicaid