Provider Demographics
NPI:1942391024
Name:RUSSO, DENISE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WEAVER DR
Mailing Address - Street 2:5B
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5679
Mailing Address - Country:US
Mailing Address - Phone:516-376-0678
Mailing Address - Fax:516-352-3037
Practice Address - Street 1:40 WEAVER DR
Practice Address - Street 2:5B
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5679
Practice Address - Country:US
Practice Address - Phone:516-376-0678
Practice Address - Fax:516-352-3037
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2009-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008494235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist