Healthcare Provider Details

I. General information

NPI: 1649657925
Provider Name (Legal Business Name): KATHRYN TERESA D'AGOSTINO RUSSO CCC-SLP, TSSLD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19502 69TH AVE
FRESH MEADOWS NY
11365-4031
US

IV. Provider business mailing address

11 HAWTHORNE ST
LYNBROOK NY
11563-1006
US

V. Phone/Fax

Practice location:
  • Phone: 516-982-4023
  • Fax:
Mailing address:
  • Phone: 516-982-4023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number024439-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: