Provider Demographics
NPI:1124654546
Name:RUSS, MAUREEN
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 N FORK CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3548
Mailing Address - Country:US
Mailing Address - Phone:303-817-5055
Mailing Address - Fax:
Practice Address - Street 1:5520 N FORK CT
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3548
Practice Address - Country:US
Practice Address - Phone:303-817-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0003904235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist