Provider Demographics
NPI:1013946417
Name:RUSSO, MATTHEW JOHN (MS, CCC-A)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 406153
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1876
Mailing Address - Country:US
Mailing Address - Phone:978-532-6650
Mailing Address - Fax:
Practice Address - Street 1:7 ESSEX GREEN DR
Practice Address - Street 2:SUITE 2
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2961
Practice Address - Country:US
Practice Address - Phone:978-532-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA777231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5104378Medicaid
MA04096401Medicare PIN
MARU040964Medicare PIN