Provider Demographics
NPI:1922521343
Name:RUSSELL, LORETTA J (SLP)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:J
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:3300 CHANDLER RD STE 115
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-4909
Mailing Address - Country:US
Mailing Address - Phone:918-684-9999
Mailing Address - Fax:888-663-4223
Practice Address - Street 1:3300 CHANDLER RD STE 115
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-4909
Practice Address - Country:US
Practice Address - Phone:918-684-9999
Practice Address - Fax:888-663-4223
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2382235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist