Provider Demographics
NPI:1154199693
Name:RUSSELL, OLIVIA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:RUSSELL
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 1:401 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:THAYER
Mailing Address - State:MO
Mailing Address - Zip Code:65791-1533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:THAYER
Practice Address - State:MO
Practice Address - Zip Code:65791-1533
Practice Address - Country:US
Practice Address - Phone:417-264-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant