Provider Demographics
NPI:1073834172
Name:VIRGO RUSSO, KIMBERLY (DT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:VIRGO RUSSO
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:VIRGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DT
Mailing Address - Street 1:7208 W LUNT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1125
Mailing Address - Country:US
Mailing Address - Phone:708-717-6594
Mailing Address - Fax:
Practice Address - Street 1:2818 S TRIPP AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4336
Practice Address - Country:US
Practice Address - Phone:773-240-5377
Practice Address - Fax:815-377-2424
Is Sole Proprietor?:No
Enumeration Date:2010-06-13
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist