Provider Demographics
NPI:1326470303
Name:MASSE, RUSSEL JOHN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:RUSSEL
Middle Name:JOHN
Last Name:MASSE
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 LONSDALE AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-1821
Mailing Address - Country:US
Mailing Address - Phone:401-465-7770
Mailing Address - Fax:
Practice Address - Street 1:1356 LONSDALE AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-1821
Practice Address - Country:US
Practice Address - Phone:401-465-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01737225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist