Provider Demographics
NPI:1316402894
Name:RUSSO, CARLY ELIZABETH (DPT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ELIZABETH
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 VICTORY AVE APT 264
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-7720
Mailing Address - Country:US
Mailing Address - Phone:610-737-8046
Mailing Address - Fax:
Practice Address - Street 1:2425 VICTORY AVE APT 264
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-7720
Practice Address - Country:US
Practice Address - Phone:610-737-8046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1315328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist