Provider Demographics
NPI:1043649338
Name:RUSSELL, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 RUTHERFORD RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-3927
Mailing Address - Country:US
Mailing Address - Phone:864-250-0005
Mailing Address - Fax:864-250-0028
Practice Address - Street 1:1132 RUTHERFORD RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-3927
Practice Address - Country:US
Practice Address - Phone:864-250-0005
Practice Address - Fax:864-250-0028
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5212235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPO333Medicaid