Provider Demographics
NPI:1487151635
Name:RUSSO, KIERA O'CONNOR
Entity type:Individual
Prefix:
First Name:KIERA
Middle Name:O'CONNOR
Last Name:RUSSO
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 1:627 ELMWOOD TER
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3713
Mailing Address - Country:US
Mailing Address - Phone:860-709-7272
Mailing Address - Fax:
Practice Address - Street 1:160 WALLACE WAY BLDG 9
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-6215
Practice Address - Country:US
Practice Address - Phone:585-617-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027587235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist