Provider Demographics
NPI:1093016610
Name:RUSSELL, SUSANNA (MPT)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:
Other - Last Name:LOUIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:312 W J ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4073
Mailing Address - Country:US
Mailing Address - Phone:209-827-6178
Mailing Address - Fax:209-827-6179
Practice Address - Street 1:312 W J ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4073
Practice Address - Country:US
Practice Address - Phone:209-827-6178
Practice Address - Fax:209-827-6179
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist