Provider Demographics
NPI:1235336462
Name:RUSSELL, KRISTA (PT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 CAT TAIL LN
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-7104
Mailing Address - Country:US
Mailing Address - Phone:740-374-2107
Mailing Address - Fax:
Practice Address - Street 1:100 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-2016
Practice Address - Country:US
Practice Address - Phone:860-224-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH010164225100000X
CT005597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist