Provider Demographics
NPI:1467614487
Name:RUSSO, MICHELLE E (LCMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 RESERVOIR AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6055
Mailing Address - Country:US
Mailing Address - Phone:401-943-2500
Mailing Address - Fax:
Practice Address - Street 1:1145 RESERVOIR AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6055
Practice Address - Country:US
Practice Address - Phone:401-943-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT00862172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist