Healthcare Provider Details

I. General information

NPI: 1992669477
Provider Name (Legal Business Name): CHRISTOPHER NEEL RUSSIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 MADRONA DR SE
PORT ORCHARD WA
98366-2752
US

IV. Provider business mailing address

PO BOX 274
ALLYN WA
98524-0274
US

V. Phone/Fax

Practice location:
  • Phone: 360-874-6160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSP61159329
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: