Provider Demographics
NPI:1730584749
Name:RUSSELL, VICTORIA ELIZABETH (MS)
Entity type:Individual
Prefix:MISS
First Name:VICTORIA
Middle Name:ELIZABETH
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 1:1330 LANGDON ST
Mailing Address - Street 2:APT. A
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-3610
Mailing Address - Country:US
Mailing Address - Phone:618-670-9391
Mailing Address - Fax:
Practice Address - Street 1:1330 LANGDON ST
Practice Address - Street 2:APT. A
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-3610
Practice Address - Country:US
Practice Address - Phone:618-670-9391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.003254235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist