Healthcare Provider Details

I. General information

NPI: 1730598814
Provider Name (Legal Business Name): MARY RUSSELL MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12170 CORTEZ BLVD
SPRING HILL FL
34613-5578
US

IV. Provider business mailing address

5063 CHAMBER CT
SPRING HILL FL
34609-1608
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-5100
  • Fax:
Mailing address:
  • Phone: 727-364-1077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5405
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA14236
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: