Provider Demographics
NPI:1073863932
Name:RUSSO, WHITNEY
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:RUSSO
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 1:12 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06612-2213
Mailing Address - Country:US
Mailing Address - Phone:076-574-5982
Mailing Address - Fax:
Practice Address - Street 1:2900 MAIN ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-4946
Practice Address - Country:US
Practice Address - Phone:203-378-0092
Practice Address - Fax:203-375-4540
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9519225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist