Basic Information
| Provider Information | |||||||||
| NPI: | 1326538638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | FAWN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6255 | ||||||||
| Address2: | |||||||||
| City: | ROCK ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612046255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144293332 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 AVENUE OF THE CITIES | ||||||||
| Address2: | |||||||||
| City: | EAST MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612444031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097961251 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2018 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 091685 | IA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 146.015288 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.