Provider Demographics
NPI:1417151762
Name:RUSSELL, REBECCA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 PLUM RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROARING RIVER
Mailing Address - State:NC
Mailing Address - Zip Code:28669-8377
Mailing Address - Country:US
Mailing Address - Phone:336-984-4787
Mailing Address - Fax:
Practice Address - Street 1:4665 BLOWING ROCK BLVD LENOIR, NC 28645
Practice Address - Street 2:
Practice Address - City:BLOWING ROCK
Practice Address - State:NC
Practice Address - Zip Code:28605-0146
Practice Address - Country:US
Practice Address - Phone:828-898-7194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5805235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211624Medicaid