Provider Demographics
NPI:1295024719
Name:RUSSELL, DAVID D (ATP, CRTS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:ATP, CRTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 DILLON LN STE 17
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78415-5335
Mailing Address - Country:US
Mailing Address - Phone:361-808-7382
Mailing Address - Fax:361-808-7367
Practice Address - Street 1:4410 DILLON LN STE 17
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-5335
Practice Address - Country:US
Practice Address - Phone:361-808-7382
Practice Address - Fax:361-808-7367
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ATP 4124247200000X, 225CA2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No225CA2500XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1008965OtherCRTS
4124OtherATP