Provider Demographics
NPI:1386987998
Name:RUSSO, DIANE J (RPT)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 STUART DRIVE
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727
Mailing Address - Country:US
Mailing Address - Phone:631-331-4639
Mailing Address - Fax:
Practice Address - Street 1:18 STUART DRIVE
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727
Practice Address - Country:US
Practice Address - Phone:631-331-4639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist