Provider Demographics
NPI:1114057031
Name:RUSSELL, LAVERNE (PT OTR)
Entity Type:Individual
Prefix:
First Name:LAVERNE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 RIVERVIEW RD
Mailing Address - Street 2:
Mailing Address - City:SWARTHMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19081-1020
Mailing Address - Country:US
Mailing Address - Phone:610-543-1460
Mailing Address - Fax:610-541-7923
Practice Address - Street 1:101 E STATE ST
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-3109
Practice Address - Country:US
Practice Address - Phone:610-925-4545
Practice Address - Fax:610-925-4579
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT 000526 E225100000X
PAOC 000834 L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist