Provider Demographics
NPI:1104157148
Name:RUSSO, BEATA (MED, OTR/L)
Entity type:Individual
Prefix:
First Name:BEATA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MED, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 CLARK ST UNIT 1382
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-7755
Mailing Address - Country:US
Mailing Address - Phone:860-969-0207
Mailing Address - Fax:
Practice Address - Street 1:561 KING ST
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-969-0207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-14
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XH1200X
CT002840225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty