Provider Demographics
NPI:1710921234
Name:RUSSO, NICOLE Z (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:Z
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 BLUE CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:FL
Mailing Address - Zip Code:34736-8111
Mailing Address - Country:US
Mailing Address - Phone:843-655-2665
Mailing Address - Fax:
Practice Address - Street 1:577 BLUE CYPRESS DR
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-8111
Practice Address - Country:US
Practice Address - Phone:843-655-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10268235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0624Medicaid