Provider Demographics
NPI:1053405100
Name:RUSSO, RICHARD LOUIS (LCSW)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LOUIS
Last Name:RUSSO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E WASHINGTON AVE
Mailing Address - Street 2:SUITE 187
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-3041
Mailing Address - Country:US
Mailing Address - Phone:608-251-0839
Mailing Address - Fax:608-255-2752
Practice Address - Street 1:1400 E WASHINGTON AVE
Practice Address - Street 2:SUITE 187
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-3041
Practice Address - Country:US
Practice Address - Phone:608-251-0839
Practice Address - Fax:608-255-2752
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1384-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42112900Medicaid