Provider Demographics
NPI:1235543109
Name:RUSSELL, ERICA ASHLEY
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:ASHLEY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 SILVER LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-2410
Mailing Address - Country:US
Mailing Address - Phone:410-312-7631
Mailing Address - Fax:410-510-1779
Practice Address - Street 1:1080 SILVER LAKE BLVD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-2410
Practice Address - Country:US
Practice Address - Phone:410-312-7631
Practice Address - Fax:410-510-1779
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07558235Z00000X
DEO1-0001580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist