Provider Demographics
NPI:1003160128
Name:RUSSELL, SCHERESIA REN'EE (MED, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SCHERESIA
Middle Name:REN'EE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 POLLY LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4925
Mailing Address - Country:US
Mailing Address - Phone:832-206-6722
Mailing Address - Fax:
Practice Address - Street 1:105 POLLY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4925
Practice Address - Country:US
Practice Address - Phone:832-206-6722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110143235Z00000X
LA8650235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist