Provider Demographics
NPI:1598084105
Name:RUSSO, COURTNEY ADEL (AUD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ADEL
Last Name:RUSSO
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:E
Other - Last Name:ADEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE B400
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6306
Practice Address - Country:US
Practice Address - Phone:864-454-4368
Practice Address - Fax:864-241-9232
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3965231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP01059268OtherRAILROAD MEDICARE
SCSA1249Medicaid
SCQ38618Medicare UPIN
SCSA1249Medicaid