Healthcare Provider Details

I. General information

NPI: 1174144919
Provider Name (Legal Business Name): RUSSO THERAPEUTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 KING STREET
SOUTH WINDSOR CT
06074
US

IV. Provider business mailing address

850 CLARK STREET # 1382
SOUTH WINDSOR CT
06074
US

V. Phone/Fax

Practice location:
  • Phone: 860-969-0207
  • Fax: 833-491-0465
Mailing address:
  • Phone: 860-969-0207
  • Fax: 833-491-0465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. BEATA D. RUSSO
Title or Position: OWNER/OTR/L, CHT
Credential: M.ED OTR/L, CHT
Phone: 860-969-0207