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Individual

KATIE-LYNN RUSSELL

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F

Contact information

Practice address
400 W MAIN ST STE 300, RIVERHEAD, NY 11901-2813
(631) 369-0104
Mailing address
790 PARK AVE, HUNTINGTON, NY 11743-4516
(631) 427-3700

Taxonomy

Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary

Other

Enumeration date
09/01/2021
Last updated
09/01/2021
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