Provider Demographics
NPI:1982841441
Name:RUSSELL, TAMARA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:RUSSELL
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 1:1705 S CAPITAL OF TEXAS HWY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6578
Mailing Address - Country:US
Mailing Address - Phone:512-327-2083
Mailing Address - Fax:512-327-0808
Practice Address - Street 1:1705 S CAPITAL OF TEXAS HWY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-6578
Practice Address - Country:US
Practice Address - Phone:512-327-2083
Practice Address - Fax:512-327-0808
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17597235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist