Provider Demographics
NPI:1679860126
Name:RUSSIN, ANTONIA RICOBENE (MS CCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:ANTONIA
Middle Name:RICOBENE
Last Name:RUSSIN
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 LEE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-6532
Mailing Address - Country:US
Mailing Address - Phone:877-486-4140
Mailing Address - Fax:
Practice Address - Street 1:950 LEE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-6532
Practice Address - Country:US
Practice Address - Phone:877-486-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.001896235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist