Provider Demographics
NPI:1780127183
Name:RUSSELLO, SALENNA (TLLP)
Entity type:Individual
Prefix:
First Name:SALENNA
Middle Name:
Last Name:RUSSELLO
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 MAURICE BLVD
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08242-1228
Mailing Address - Country:US
Mailing Address - Phone:609-602-6597
Mailing Address - Fax:
Practice Address - Street 1:1030 MINERS RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9625
Practice Address - Country:US
Practice Address - Phone:269-408-1688
Practice Address - Fax:269-408-1692
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016962103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling