Provider Demographics
NPI:1902180573
Name:RUSSO REHABILITATION, LLC
Entity Type:Organization
Organization Name:RUSSO REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO; OWNER; OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:RUSSO
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:678-462-2923
Mailing Address - Street 1:505 LOUVOIS ST
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-5468
Mailing Address - Country:US
Mailing Address - Phone:678-462-2923
Mailing Address - Fax:866-753-4652
Practice Address - Street 1:505 LOUVOIS ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-5468
Practice Address - Country:US
Practice Address - Phone:678-462-2923
Practice Address - Fax:866-753-4652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-30
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Single Specialty
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental ModificationGroup - Single Specialty
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & SwallowingGroup - Single Specialty
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental HealthGroup - Single Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2450514Medicaid