Provider Demographics
NPI:1225344039
Name:RUSSELL, LORRAINE ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:ELIZABETH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 PEACHTREE RD NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1476
Mailing Address - Country:US
Mailing Address - Phone:404-605-1982
Mailing Address - Fax:
Practice Address - Street 1:2001 PEACHTREE RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1476
Practice Address - Country:US
Practice Address - Phone:404-605-1982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000518225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist