Provider Demographics
NPI:1346278272
Name:RUSSO, THERESE EILEEN (MA)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:EILEEN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 ROUTE 146
Mailing Address - Street 2:BUILDING 300 STE 302
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3646
Mailing Address - Country:US
Mailing Address - Phone:518-383-4273
Mailing Address - Fax:518-383-4274
Practice Address - Street 1:989 ROUTE 146
Practice Address - Street 2:BUILDING 300 STE 302
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3646
Practice Address - Country:US
Practice Address - Phone:518-383-4273
Practice Address - Fax:518-383-4274
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0005651231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA0844Medicare ID - Type Unspecified