Basic Information
| Provider Information | |||||||||
| NPI: | 1275851404 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | HELEN | ||||||||
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| Credential: | CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 MARYLAND FARMS STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153455400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 N OCEAN BLVD | ||||||||
| Address2: | # 602 | ||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330624644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153455400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2010 | ||||||||
| LastUpdateDate: | 12/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 02015 | MO | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | AY1727 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.