Provider Demographics
NPI:1609349158
Name:TRUSSELL, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:TRUSSELL
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 1:13206 EDDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1943
Mailing Address - Country:US
Mailing Address - Phone:240-305-5956
Mailing Address - Fax:
Practice Address - Street 1:1400 NALLEY TER
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4434
Practice Address - Country:US
Practice Address - Phone:240-696-3210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04494235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty