Provider Demographics
NPI:1881989028
Name:RUSSELL, DIANA KAY (SLP)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:KAY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 MILL HOLLOW XING
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-1084
Mailing Address - Country:US
Mailing Address - Phone:585-225-4552
Mailing Address - Fax:
Practice Address - Street 1:198 MILL HOLLOW XING
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-1084
Practice Address - Country:US
Practice Address - Phone:585-225-4552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012359-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12014358OtherNYS LICENSE NUMBER012359-1