Provider Demographics
NPI:1588113112
Name:RUSSELL, MADISON N (SLP)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:N
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:N
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:1810 MACKENZIE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:974 BETHEL RD
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-2467
Practice Address - Country:US
Practice Address - Phone:614-538-2424
Practice Address - Fax:614-538-2418
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND2017081SP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist