Provider Demographics
NPI:1093734998
Name:RUSSO, SHERIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHERIE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 JERICHO TPKE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4505
Mailing Address - Country:US
Mailing Address - Phone:516-364-6720
Mailing Address - Fax:
Practice Address - Street 1:567 JERICHO TPKE
Practice Address - Street 2:SUITE 202
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4505
Practice Address - Country:US
Practice Address - Phone:516-364-6720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012153-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQMedicare ID - Type UnspecifiedPROVIDER NUMBER