Provider Demographics
NPI:1518001536
Name:RUSSO, MARYANN C (PT)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:C
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3632 WILDWOOD ST
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-1129
Mailing Address - Country:US
Mailing Address - Phone:845-528-3133
Mailing Address - Fax:
Practice Address - Street 1:21 PEEKSKILL HOLLOW RD
Practice Address - Street 2:STE 201
Practice Address - City:PUTNAM VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10579-3248
Practice Address - Country:US
Practice Address - Phone:845-528-3133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004832225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ53311Medicare ID - Type Unspecified
NYQ53312Medicare ID - Type Unspecified