Provider Demographics
NPI:1902572688
Name:RUSSO, ROBERTA (CSW008127)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CSW008127
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 FIRST COTTON DR
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6237
Mailing Address - Country:US
Mailing Address - Phone:404-396-4761
Mailing Address - Fax:
Practice Address - Street 1:3911 MARY ELIZA TRCE NW STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1088
Practice Address - Country:US
Practice Address - Phone:678-631-9907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0081271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical