MEDICARE: EMILY RUSSELL

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

General Provider Information

NPI Number	:	1396264966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY RUSSELL

Provider Business Mailing Address
First Line	:	28 PATTERSON VILLAGE DR APT 4
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45419-4219
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1313 E 5TH ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45402-2222
Country	:	US
Telephone Number	:	937-542-7454
Fax Number	:

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

Provider Enumeration Date	:	09/15/2017
Last Update Date	:	09/15/2017

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Directions to “ EMILY RUSSELL ” Practice Location

Language	Start Address	Practice Location

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