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General NPI Number Information
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NPI Number | 1003931577
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Entity Type | Individual
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Provider Name | RYAN RUSSELL MSSLP.CCC
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Gender | Male
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 6701 HIGHWAY 67
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City | BENTON
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State | AR
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Zip | 72015-8909
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Country | US
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Telephone | 501-860-0777
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Fax |
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Provider Business Mailing Address
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Address Line | 1125 CHARLSEA LN
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City | BENTON
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State | AR
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Zip | 72015-2390
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Country | US
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Telephone | 501-860-0777
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SP #2073
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License Number State | AR
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