Healthcare Provider Details

I. General information

NPI: 1073863932
Provider Name (Legal Business Name): WHITNEY RUSSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 MAIN ST SUITE 1D
STRATFORD CT
06614-4946
US

IV. Provider business mailing address

12 DOGWOOD DR
EASTON CT
06612-2213
US

V. Phone/Fax

Practice location:
  • Phone: 203-378-0092
  • Fax: 203-375-4540
Mailing address:
  • Phone: 76-574-5982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9519
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: