Provider Demographics
NPI:1326750050
Name:RUSS, VERONICA (LMBT)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5831 FINESTRA WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-4198
Mailing Address - Country:US
Mailing Address - Phone:919-389-6141
Mailing Address - Fax:
Practice Address - Street 1:5831 FINESTRA WAY
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-4198
Practice Address - Country:US
Practice Address - Phone:919-389-6141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16730225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist