Provider Demographics
NPI:1063854529
Name:RUSSELL, BENJAMIN (AUD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 E FOWLER AVE
Mailing Address - Street 2:PCD1017
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33620-8200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:PCD1017
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-8200
Practice Address - Country:US
Practice Address - Phone:813-974-8804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1685231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist