Provider Demographics
NPI:1235388380
Name:RUSSELL, ELIZABETH M (LMT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
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:PO BOX 53428
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79453-3428
Mailing Address - Country:US
Mailing Address - Phone:806-792-4041
Mailing Address - Fax:806-209-0105
Practice Address - Street 1:3132 50TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-4104
Practice Address - Country:US
Practice Address - Phone:806-792-4041
Practice Address - Fax:806-209-0105
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-13
Last Update Date:2008-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT031611225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist