Provider Demographics
NPI:1790441541
Name:HYSLOP, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:HYSLOP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11217 NW 25TH CT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-4421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11104 NE 149TH ST
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-9565
Practice Address - Country:US
Practice Address - Phone:360-389-7588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist