Provider Demographics
NPI:1144880279
Name:RUSSO, ALISON BRIDGES (LCSW)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:BRIDGES
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ALISON
Other - Middle Name:BRIDGES
Other - Last Name:PHLEGAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:6180 PROVIDENCE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-8723
Mailing Address - Country:US
Mailing Address - Phone:336-757-2501
Mailing Address - Fax:336-277-4634
Practice Address - Street 1:175 KIMEL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6951
Practice Address - Country:US
Practice Address - Phone:336-718-3550
Practice Address - Fax:336-277-1825
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0089961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical