Provider Demographics
NPI:1194390963
Name:RUSSELL, JULIE LAINE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:LAINE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 EUBANK BLVD NE APT 1021
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-7317
Mailing Address - Country:US
Mailing Address - Phone:908-601-1811
Mailing Address - Fax:
Practice Address - Street 1:9150 MCMAHON BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5201
Practice Address - Country:US
Practice Address - Phone:505-898-7986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOT4456225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation