Provider Demographics
NPI:1275851404
Name:RUSSO, MARY HELEN (CCC-A)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:HELEN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MARYLAND FARMS STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5780
Mailing Address - Country:US
Mailing Address - Phone:615-345-5400
Mailing Address - Fax:
Practice Address - Street 1:750 N OCEAN BLVD
Practice Address - Street 2:# 602
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-4644
Practice Address - Country:US
Practice Address - Phone:615-345-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO02015231H00000X
FLAY1727231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist