Provider Demographics
NPI:1780353987
Name:RUSSO, ERIN
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:RUSSO
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 1:10 PHELPS RD
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:CT
Mailing Address - Zip Code:06447-1227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 CENTRE ST STE 6&7
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:CT
Practice Address - Zip Code:06420-3844
Practice Address - Country:US
Practice Address - Phone:860-949-2561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6246225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics