Kelly L Russo, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PY-8336 Issued in FL

Practice address

1767 Village Park Dr
Orangeburg, SC 29118-2475

Phone

(803) 776-4000

Fax

(803) 536-1719

NPI assigned

Aug 18, 2009

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Kelly L Davis Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1250553600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1398902400000",
    "number": "1265664734",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "715 DARLINGTON ST",
            "city": "COLUMBIA",
            "state": "SC",
            "postal_code": "292011201",
            "telephone_number": "239-314-8511"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1767 VILLAGE PARK DR",
            "city": "ORANGEBURG",
            "state": "SC",
            "postal_code": "291182475",
            "telephone_number": "803-776-4000",
            "fax_number": "803-536-1719"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "RUSSO",
        "first_name": "KELLY",
        "middle_name": "L",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2009-08-18",
        "last_updated": "2014-05-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "FL",
            "license": "PY-8336",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "54516",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KELLY",
            "last_name": "DAVIS",
            "middle_name": "L",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Royal Non Emergency Medical Transportation
• Veronica Rubio
• Crystal Victoria Rucker
• Jordana Ruffner, D.O.
• Eunice M Rush-Howell
• S.C. Department of Health and Environmental Control
• S.C. State University
• Safiyah J Salih, DDS
• Jodi Salley, SLP
• Lawton Haris Salley, MD

• Clinical Psychologist in Orangeburg, SC
• Providers in Orangeburg, SC by specialty
• Clinical Psychologist in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.