Provider Demographics
NPI:1730598814
Name:RUSSELL, MARY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5063 CHAMBER CT
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-1608
Mailing Address - Country:US
Mailing Address - Phone:727-364-1077
Mailing Address - Fax:
Practice Address - Street 1:12170 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34613-5578
Practice Address - Country:US
Practice Address - Phone:352-597-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5405235Z00000X
FLSA14236235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist