Provider Demographics
NPI:1871764829
Name:RUSSO, ERIN MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:MICHELLE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 DOLPHIN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2937
Mailing Address - Country:US
Mailing Address - Phone:716-774-8745
Mailing Address - Fax:
Practice Address - Street 1:191 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-3519
Practice Address - Country:US
Practice Address - Phone:716-692-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27 009931225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist