Provider Demographics
NPI:1558547489
Name:RUSSO, LORI LYNN (OT)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:LYNN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-1502
Mailing Address - Country:US
Mailing Address - Phone:414-529-9982
Mailing Address - Fax:
Practice Address - Street 1:W143N5009 BROOK FALLS DR
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-6987
Practice Address - Country:US
Practice Address - Phone:262-781-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3208-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist