Provider Demographics
NPI:1851062459
Name:RUSSO, KAITLIN ASHLI (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ASHLI
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 GUYON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2018
Mailing Address - Country:US
Mailing Address - Phone:718-979-7013
Mailing Address - Fax:
Practice Address - Street 1:69 GUYON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2018
Practice Address - Country:US
Practice Address - Phone:718-979-7013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist