Provider Demographics
NPI:1548094964
Name:RUSSO, KALLISTA
Entity type:Individual
Prefix:
First Name:KALLISTA
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 1:38 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-7461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 GORDONS CORNER RD STE 2
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3150
Practice Address - Country:US
Practice Address - Phone:732-851-7642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02283600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist