Active NPI
Michelle Russo
- Pediatric Occupational Therapist
- Lake City, FL
National Provider Identifier
1790546414
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Occupational Therapist
- License
- OT24825
- Practice address
- 3650 NW Devane St
Lake City, FL 32055-8730 - Phone
- (386) 758-1811
- NPI assigned
- Jan 19, 2024
- Last updated
- Jan 19, 2024
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Occupational Therapist | 225XP0200X | OT24825 | FL | Primary |
Addresses
Primary practice location
3650 NW Devane St
Lake City, FL 32055-8730
Mailing address
1388 Bitterberry Dr
Orange Park, FL 32065-5239
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| OT24825 | FL | MD | Pediatric Occupational Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1705622400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1705622400000",
"number": "1790546414",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1388 BITTERBERRY DR",
"city": "ORANGE PARK",
"state": "FL",
"postal_code": "320655239"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3650 NW DEVANE ST",
"city": "LAKE CITY",
"state": "FL",
"postal_code": "320558730",
"telephone_number": "386-758-1811"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RUSSO",
"first_name": "MICHELLE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2024-01-19",
"last_updated": "2024-01-19",
"certification_date": "2024-01-19",
"status": "A"
},
"taxonomies": [
{
"code": "225XP0200X",
"taxonomy_group": "",
"desc": "Occupational Therapist, Pediatrics",
"state": "FL",
"license": "OT24825",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Lake City, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.