Provider Demographics
NPI:1093473159
Name:RUSSELL, OLIVIA SHEA (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:SHEA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11721 RED OAK VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78732-2406
Mailing Address - Country:US
Mailing Address - Phone:512-569-0388
Mailing Address - Fax:
Practice Address - Street 1:14651 DALLAS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8856
Practice Address - Country:US
Practice Address - Phone:866-919-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119148235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist