MEDICARE: KIMBERLY VIRGO RUSSO DT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist		IL

General Provider Information

NPI Number	:	1073834172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY VIRGO RUSSO DT

Provider Business Mailing Address
First Line	:	7208 W LUNT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-1125
Country	:	US
Telephone Number	:	708-717-6594
Fax Number	:

Provider Business Practice Location Address
First Line	:	2818 S TRIPP AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-4336
Country	:	US
Telephone Number	:	773-240-5377
Fax Number	:	815-377-2424

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2010
Last Update Date	:	06/30/2016

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Directions to “ KIMBERLY VIRGO RUSSO DT” Practice Location

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