Provider Demographics
NPI:1518253004
Name:RUSSO, JOANNE
Entity Type:Individual
Prefix:
First Name:JOANNE
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 1:960 W TOWN AND COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4714
Mailing Address - Country:US
Mailing Address - Phone:714-836-7886
Mailing Address - Fax:714-836-1109
Practice Address - Street 1:960 W TOWN AND COUNTRY RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4714
Practice Address - Country:US
Practice Address - Phone:714-836-7886
Practice Address - Fax:714-836-1109
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 112412251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics