Healthcare Provider Details

I. General information

NPI: 1104157148
Provider Name (Legal Business Name): BEATA RUSSO M.ED, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 KING ST
SOUTH WINDSOR CT
06074
US

IV. Provider business mailing address

850 CLARK ST UNIT 1382
SOUTH WINDSOR CT
06074-7755
US

V. Phone/Fax

Practice location:
  • Phone: 860-969-0207
  • Fax:
Mailing address:
  • Phone: 860-969-0207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number002840
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: