Provider Demographics
NPI:1982187985
Name:RUSSO, KAREN MARIE
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 STONEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-1546
Mailing Address - Country:US
Mailing Address - Phone:310-779-3654
Mailing Address - Fax:
Practice Address - Street 1:916 N WESTERN AVE STE 205
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-2435
Practice Address - Country:US
Practice Address - Phone:310-779-3654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty