Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | ||
N | 103G00000X | Clinical Psychologist | 2943 | MA |
N | 103TC0700X | Clinical Psychologist | 2943 | MA |
NPI | 1609867670 |
---|---|
Provider Name | Dr. Robert Gerard Dello Russo |
First Address | Boston, MA 02116-6103 |
Second Address | Boston, MA 02116-6103 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
R84937 | (02) | MA |