Provider Demographics
NPI:1578813960
Name:RUSSELL, ERIN E (SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:E
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 CRAIG DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143
Mailing Address - Country:US
Mailing Address - Phone:719-352-8626
Mailing Address - Fax:719-352-8626
Practice Address - Street 1:304 CRAIG DR
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-3047
Practice Address - Country:US
Practice Address - Phone:719-352-8626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#3773235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111408402Medicaid
TX456554Medicare PIN