Provider Demographics
NPI:1275736654
Name:RUSSELL, KIRSTEN M (SLP)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1062 W MILLS ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722-8635
Practice Address - Country:US
Practice Address - Phone:828-894-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7427235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist