Provider Demographics
NPI:1457021198
Name:RUSSO, ANTONIA
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
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 1:909 TYLER CIR
Mailing Address - Street 2:
Mailing Address - City:STEWARTSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08886-2605
Mailing Address - Country:US
Mailing Address - Phone:908-565-2456
Mailing Address - Fax:
Practice Address - Street 1:290 RED SCHOOL LN
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-2276
Practice Address - Country:US
Practice Address - Phone:908-859-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist