Healthcare Provider Details

I. General information

NPI: 1053222406
Provider Name (Legal Business Name): ALEXA RUSSO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6409 CITY WEST PKWY STE 206
EDEN PRAIRIE MN
55344-7846
US

IV. Provider business mailing address

8746 PRESCOTT DR
EDEN PRAIRIE MN
55347-2249
US

V. Phone/Fax

Practice location:
  • Phone: 952-500-8871
  • Fax:
Mailing address:
  • Phone: 952-300-7731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: