Provider Demographics
NPI:1053790527
Name:RIFKIN-RUSSELL, PHYLLIS (MS)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:RIFKIN-RUSSELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:JANE
Other - Last Name:RIFKIN-RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:26 THACKERY RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-3361
Mailing Address - Country:US
Mailing Address - Phone:585-232-2280
Mailing Address - Fax:
Practice Address - Street 1:26 THACKERY RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-3361
Practice Address - Country:US
Practice Address - Phone:585-232-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000559-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health