Provider Demographics
NPI:1295385102
Name:RUSSO, RENATA R
Entity Type:Individual
Prefix:
First Name:RENATA
Middle Name:R
Last Name:RUSSO
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 1:660 WHITE PLAINS ROAD - ENTA
Mailing Address - Street 2:FOURTH FLOOR
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-6802
Mailing Address - Country:US
Mailing Address - Phone:914-984-2552
Mailing Address - Fax:
Practice Address - Street 1:2651 STRANG BOULEVARD
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598
Practice Address - Country:US
Practice Address - Phone:914-245-2681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
NY14000055942237700000X
NY11228231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist