Active NPI
Stephen John Russo, PHD
- Clinical Psychologist
- Mineola, NY
National Provider Identifier
1093826778
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 0113131
- Practice address
- 302 Willis Avenue
Mineola, NY 11501 - Phone
- (516) 448-3015
- NPI assigned
- Aug 31, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 0113131 | NY | Primary |
Addresses
Primary practice location
302 Willis Avenue
Mineola, NY 11501
Mailing address
20 Whistlerhill Lane
Huntington, NY 11743
Phone (516) 448-3015
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 01527119 | Medicaid | NY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NY
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20110308000219 | NY | Practitioner - Clinical Psychologist | 5092997353 | Practice locations: Mineola, NY |
Care Compare profile
Medicare Care Compare- Specialty
- Clinical Psychologist
- Education
- Other, 1991
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Telehealth
- Offers telehealth services
Practice addresses (Care Compare)
302 Willis Ave
Mineola, NY 11501-1521
Phone (516) 448-3015
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 011313 | NY | MD | Mental Health Counselor |
| 0113131 | NY | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156982400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1093826778",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "20 WHISTLERHILL LANE",
"city": "HUNTINGTON",
"state": "NY",
"postal_code": "11743",
"telephone_number": "516-448-3015"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "302 WILLIS AVENUE",
"city": "MINEOLA",
"state": "NY",
"postal_code": "11501",
"telephone_number": "516-448-3015"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RUSSO",
"first_name": "STEPHEN",
"middle_name": "JOHN",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-31",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "NY",
"license": "0113131",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "01527119",
"state": "NY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Mineola, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.