Provider Demographics
NPI:1700370772
Name:LARUSSA, REBECCA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:LARUSSA
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 1:121 SWINICK DR
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-2078
Mailing Address - Country:US
Mailing Address - Phone:570-687-5485
Mailing Address - Fax:
Practice Address - Street 1:532 GIBSON DR STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-5878
Practice Address - Country:US
Practice Address - Phone:866-564-3589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11267235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist