MEDICARE: SUSAN M. RUSSELL M.A.,C.C.C.

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	235Z00000X	Speech-Language Pathologist	383	OK

General Provider Information

NPI Number	:	1194733618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M. RUSSELL M.A.,C.C.C.

Provider Business Mailing Address
First Line	:	10749 E 29TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129-7805
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10749 E 29TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129-7805
Country	:	US
Telephone Number	:	918-663-7832
Fax Number	:

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

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	07/08/2007

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