Provider Demographics
NPI:1154099042
Name:RUSSO, CATHLEEN P (LMT)
Entity Type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:P
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-1621
Mailing Address - Country:US
Mailing Address - Phone:516-302-3460
Mailing Address - Fax:
Practice Address - Street 1:64 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-1621
Practice Address - Country:US
Practice Address - Phone:516-302-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031790-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist