Provider Demographics
NPI:1194020065
Name:RUSSELL, TERISA BAY (LMT)
Entity Type:Individual
Prefix:
First Name:TERISA
Middle Name:BAY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TERISA
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:TERISA RUSSELL(LMT)
Mailing Address - Street 1:2836 HUNT CLUB LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-3912
Mailing Address - Country:US
Mailing Address - Phone:407-595-9130
Mailing Address - Fax:
Practice Address - Street 1:110 N ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5574
Practice Address - Country:US
Practice Address - Phone:407-324-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-24
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42761225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist