Provider Demographics
NPI:1003180472
Name:RUSS, BERKELEY R (COTA/L)
Entity Type:Individual
Prefix:MISS
First Name:BERKELEY
Middle Name:R
Last Name:RUSS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4523 PRESCOTT AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-4964
Mailing Address - Country:US
Mailing Address - Phone:320-226-4591
Mailing Address - Fax:
Practice Address - Street 1:1133 N 3RD ST
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:NE
Practice Address - Zip Code:68450-2069
Practice Address - Country:US
Practice Address - Phone:402-335-3357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE856224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant