Healthcare Provider Details

I. General information

NPI: 1104053529
Provider Name (Legal Business Name): KELLY RUSSO STONE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY ANN RUSSO OTR/L

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 LOUVOIS ST
MANDEVILLE LA
70448-5468
US

IV. Provider business mailing address

505 LOUVOIS ST
MANDEVILLE LA
70448-5468
US

V. Phone/Fax

Practice location:
  • Phone: 678-462-2923
  • Fax: 866-753-4652
Mailing address:
  • Phone: 678-462-2923
  • Fax: 866-753-4652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License NumberOTT.Z1156
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License NumberOTT.Z1156
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License NumberOTT.Z1156
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOTT.Z1156
License Number StateLA
# 5
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTT.Z1156
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: