Healthcare Provider Details

I. General information

NPI: 1780353987
Provider Name (Legal Business Name): ERIN RUSSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 10/16/2026
Certification Date: 10/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 PENDLETON DR
HEBRON CT
06248-1512
US

IV. Provider business mailing address

55 STONERIDGE RD
COLCHESTER CT
06415-2348
US

V. Phone/Fax

Practice location:
  • Phone: 860-207-3665
  • Fax: 860-812-2151
Mailing address:
  • Phone: 860-682-4248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number6246
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: