Provider Demographics
NPI:1710308101
Name:RUSSO, ERIN
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
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 1:3801 SCHROER ROAD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605
Mailing Address - Country:US
Mailing Address - Phone:229-244-3552
Mailing Address - Fax:229-244-7030
Practice Address - Street 1:3801 SCHROER ROAD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605
Practice Address - Country:US
Practice Address - Phone:229-244-3552
Practice Address - Fax:229-244-7030
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET001888235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPCET001888OtherLICENSE NUMBER