Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1013151067 |
---|---|
Provider Name | Lori Russo |
First Address | Irving, TX 75063-2712 |
Second Address | Irving, TX 75063-2712 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2009 |
Last Update Date | 21/04/2009 |