Healthcare Provider Details

I. General information

NPI: 1467614487
Provider Name (Legal Business Name): MICHELLE E RUSSO LCMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 RESERVOIR AVE STE 210
CRANSTON RI
02920-6000
US

IV. Provider business mailing address

1145 RESERVOIR AVE STE 210
CRANSTON RI
02920-6000
US

V. Phone/Fax

Practice location:
  • Phone: 401-749-0662
  • Fax:
Mailing address:
  • Phone: 401-749-0662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMT00862
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: