Provider Demographics
NPI:1326367061
Name:RUSSELL, KRISTIE SMITH (COTA)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:SMITH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 E CHURCH ST
Mailing Address - Street 2:BLDG A 102
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-4104
Mailing Address - Country:US
Mailing Address - Phone:863-677-4605
Mailing Address - Fax:
Practice Address - Street 1:2120 MARSHALL EDWARDS DR
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-6731
Practice Address - Country:US
Practice Address - Phone:863-534-1862
Practice Address - Fax:863-619-6059
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11145224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant