Provider Demographics
NPI:1760265672
Name:RUSSO, CHELSEA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
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 1:187 KAKEOUT RD
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2538
Mailing Address - Country:US
Mailing Address - Phone:973-270-4487
Mailing Address - Fax:
Practice Address - Street 1:187 KAKEOUT RD
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2538
Practice Address - Country:US
Practice Address - Phone:973-270-4487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01178200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist