Provider Demographics
NPI:1992776850
Name:RUSSO, LYNN (SLPCCC)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:SLPCCC
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1205 GROVE ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-232-6833
Mailing Address - Fax:
Practice Address - Street 1:5006 COPPER NE
Practice Address - Street 2:EXPLORABILITIES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-268-7988
Practice Address - Fax:505-268-8021
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1033235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist