Basic Information
| Provider Information | |||||||||
| NPI: | 1558547489 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | RUSSO | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1680 BERKSHIRE DR | ||||||||
| Address2: | |||||||||
| City: | ELM GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531221502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145299982 | ||||||||
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| Practice Location | |||||||||
| Address1: | W143N5009 BROOK FALLS DR | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530516987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627818352 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2008 | ||||||||
| LastUpdateDate: | 01/09/2008 | ||||||||
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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 | 225X00000X | 3208-026 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.