Provider Demographics
NPI:1831437060
Name:RUSS, DEANDRA (MS, CCC/SP)
Entity type:Individual
Prefix:
First Name:DEANDRA
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:MS, CCC/SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2402
Mailing Address - Country:US
Mailing Address - Phone:606-547-5561
Mailing Address - Fax:270-465-0068
Practice Address - Street 1:121 CASEY ST STE A
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-6858
Practice Address - Country:US
Practice Address - Phone:270-465-7768
Practice Address - Fax:270-465-0068
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12087235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist