Provider Demographics
NPI:1164560025
Name:RUSSO, LEAH GILLGANNON (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:LEAH
Middle Name:GILLGANNON
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:THERESE
Other - Last Name:GILLGANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-4407
Mailing Address - Country:US
Mailing Address - Phone:516-455-7686
Mailing Address - Fax:
Practice Address - Street 1:14 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-4407
Practice Address - Country:US
Practice Address - Phone:516-455-7686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012538-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist