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General NPI Number Information
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NPI Number | 1245050269
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Entity Type | Individual
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Provider Name | PAIGE LILLIAN RUSSO
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Gender | Female
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Dates
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Enumeration Date | 10/14/2024
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Last Update Date | 10/14/2024
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Provider Practice Location Address
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Address Line | 3584 MOUNT ZION CHURCH RD
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City | VALDOSTA
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State | GA
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Zip | 31605-6510
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Country | US
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Telephone | 229-242-1895
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Fax |
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Provider Business Mailing Address
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Address Line | 4023 TIMBER RIDGE RD
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City | VALDOSTA
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State | GA
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Zip | 31601-0225
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Country | US
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Telephone | 229-412-4056
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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 | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | 106S00000X
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License Number State | GA
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