Provider Demographics
NPI:1689343543
Name:RUSSO, KATE JULIA-SANDRA
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:JULIA-SANDRA
Last Name:RUSSO
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 1:4324 HATCH LN
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-4359
Mailing Address - Country:US
Mailing Address - Phone:630-267-8768
Mailing Address - Fax:
Practice Address - Street 1:780 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-6192
Practice Address - Country:US
Practice Address - Phone:630-375-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist