Basic Information
| Provider Information | |||||||||
| NPI: | 1477922995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 332 SIEBERTS RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600102333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474892941 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4100 VETERANS PKWY | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600508350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153441230 | ||||||||
| FaxNumber: | 8153443815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2015 | ||||||||
| LastUpdateDate: | 09/15/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.