Provider Demographics
NPI:1083854210
Name:STRAM, RUSSELL (PT, LAC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:STRAM
Suffix:
Gender:M
Credentials:PT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W 39TH ST
Mailing Address - Street 2:SUITE 708
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-3803
Mailing Address - Country:US
Mailing Address - Phone:917-484-0887
Mailing Address - Fax:
Practice Address - Street 1:55 W 39TH ST
Practice Address - Street 2:SUITE 708
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-3803
Practice Address - Country:US
Practice Address - Phone:917-484-0887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-27
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020372225100000X
NY003039171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist