Provider Demographics
NPI:1891313383
Name:RUSSO, MELANIE (MS, CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:MELANIE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 HARTFORD TPKE APT 661
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-9409
Mailing Address - Country:US
Mailing Address - Phone:203-671-8682
Mailing Address - Fax:
Practice Address - Street 1:26 SHENIPSIT LAKE RD
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-2332
Practice Address - Country:US
Practice Address - Phone:860-872-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005608235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist