Provider Demographics
NPI:1831211895
Name:RUSSO, ANTONIETTA ANNA (PHD)
Entity type:Individual
Prefix:
First Name:ANTONIETTA
Middle Name:ANNA
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 FASHION BLVD
Mailing Address - Street 2:STE 190
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6159
Mailing Address - Country:US
Mailing Address - Phone:801-314-4736
Mailing Address - Fax:
Practice Address - Street 1:5801 FASHION BLVD
Practice Address - Street 2:STE 190
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6159
Practice Address - Country:US
Practice Address - Phone:801-314-4736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT370566-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist