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General NPI Number Information
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NPI Number | 1730598814
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Entity Type | Individual
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Provider Name | MARY RUSSELL MS, CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 08/04/2014
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Last Update Date | 10/26/2015
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Provider Practice Location Address
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Address Line | 12170 CORTEZ BLVD
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City | SPRING HILL
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State | FL
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Zip | 34613-5578
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Country | US
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Telephone | 352-597-5100
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Fax |
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Provider Business Mailing Address
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Address Line | 5063 CHAMBER CT
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City | SPRING HILL
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State | FL
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Zip | 34609-1608
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Country | US
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Telephone | 727-364-1077
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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 | 5405
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SA14236
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License Number State | FL
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