Provider Demographics
NPI:1063959088
Name:RUSSO, MONA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1031
Mailing Address - Country:US
Mailing Address - Phone:415-509-3786
Mailing Address - Fax:
Practice Address - Street 1:112 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1031
Practice Address - Country:US
Practice Address - Phone:415-509-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-28
Last Update Date:2017-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23837235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist