Provider Demographics
NPI:1154282754
Name:RUSSO, LOGAN MICHAEL (BC-HIS)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:MICHAEL
Last Name:RUSSO
Suffix:
Gender:X
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8726 RAMSEY DR
Mailing Address - Street 2:
Mailing Address - City:THEODORE
Mailing Address - State:AL
Mailing Address - Zip Code:36582-7040
Mailing Address - Country:US
Mailing Address - Phone:732-503-2347
Mailing Address - Fax:
Practice Address - Street 1:8726 RAMSEY DR
Practice Address - Street 2:
Practice Address - City:THEODORE
Practice Address - State:AL
Practice Address - Zip Code:36582-7040
Practice Address - Country:US
Practice Address - Phone:732-503-2347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-21
Last Update Date:2025-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS714237700000X
AL4241237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty