Provider Demographics
NPI:1255006037
Name:RUSSELL, MADISON GRACE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:MADISON
Middle Name:GRACE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2086 PEAVINE RD
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MS
Mailing Address - Zip Code:38618-9522
Mailing Address - Country:US
Mailing Address - Phone:901-302-0997
Mailing Address - Fax:
Practice Address - Street 1:214 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2140
Practice Address - Country:US
Practice Address - Phone:662-560-0602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA7197225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant