Provider Demographics
NPI:1205267762
Name:RUSSELL, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:RUSSELL
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 1:921 GLENDORA RD S
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-3653
Mailing Address - Country:US
Mailing Address - Phone:717-226-6403
Mailing Address - Fax:
Practice Address - Street 1:12901 BROLEMAN RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-6107
Practice Address - Country:US
Practice Address - Phone:407-641-0808
Practice Address - Fax:407-812-4358
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
PASL007674235Z00000X
FLSA16793235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist