Provider Demographics
NPI:1114636255
Name:RUSSO, FILOMENA THERESA (EDUCATOR)
Entity Type:Individual
Prefix:
First Name:FILOMENA
Middle Name:THERESA
Last Name:RUSSO
Suffix:
Gender:F
Credentials:EDUCATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 GREENMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5623
Mailing Address - Country:US
Mailing Address - Phone:516-658-3420
Mailing Address - Fax:631-522-1183
Practice Address - Street 1:7 HIGH ST STE 201
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3417
Practice Address - Country:US
Practice Address - Phone:631-423-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY660315512OtherNYS DRIVERS LICENSE