Provider Demographics
NPI:1649462086
Name:RUSSELL, EMILY DIANE (MS)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:DIANE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:986 HUNTER AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3424
Mailing Address - Country:US
Mailing Address - Phone:740-815-4643
Mailing Address - Fax:
Practice Address - Street 1:986 HUNTER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-3424
Practice Address - Country:US
Practice Address - Phone:740-815-4643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2008001235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist