Provider Demographics
NPI:1184991606
Name:COHEN-RUSSO, SHANA RAE (MA CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:RAE
Last Name:COHEN-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 1:6 TARA LN
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2336
Mailing Address - Country:US
Mailing Address - Phone:631-543-1799
Mailing Address - Fax:631-543-1503
Practice Address - Street 1:6 TARA LN
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2336
Practice Address - Country:US
Practice Address - Phone:631-543-1799
Practice Address - Fax:631-543-1503
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008330-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist