Provider Demographics
NPI:1639512544
Name:RUSSELL, SARA ANN (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 SE 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79118-7773
Mailing Address - Country:US
Mailing Address - Phone:806-662-7652
Mailing Address - Fax:
Practice Address - Street 1:2102 SE 41ST AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79118
Practice Address - Country:US
Practice Address - Phone:806-662-7652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107778235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist