Provider Demographics
NPI:1598953168
Name:RUSSELL, VIRGINIA (AUDIOLOGIST)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 N FLAG CHAPEL RD
Mailing Address - Street 2:MAGNOLIA SPEECH SCHOOL
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-2206
Mailing Address - Country:US
Mailing Address - Phone:601-922-5530
Mailing Address - Fax:601-922-5534
Practice Address - Street 1:733 N FLAG CHAPEL RD
Practice Address - Street 2:MAGNOLIA SPEECH SCHOOL
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-2206
Practice Address - Country:US
Practice Address - Phone:601-922-5530
Practice Address - Fax:601-922-5534
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA2764231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02372704Medicaid