Provider Demographics
NPI:1710145180
Name:RUSSO, ELIZABETH (OTR/L)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-6909
Mailing Address - Country:US
Mailing Address - Phone:207-846-5041
Mailing Address - Fax:
Practice Address - Street 1:370 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-8101
Practice Address - Country:US
Practice Address - Phone:207-846-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT690225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist