Provider Demographics
NPI:1790280071
Name:RUSSO, SARAH LOUISE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:LOUISE
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 1:3213 BROOKEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34120-4470
Mailing Address - Country:US
Mailing Address - Phone:239-298-3045
Mailing Address - Fax:
Practice Address - Street 1:3981 WELLINGTON PKWY
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-1172
Practice Address - Country:US
Practice Address - Phone:813-402-0689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT13576225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation