Provider Demographics
NPI:1346647351
Name:RUSSELL, SHANNON LOUISE (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LOUISE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 FRONTIER TRL STE 101
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1567
Mailing Address - Country:US
Mailing Address - Phone:512-766-2649
Mailing Address - Fax:
Practice Address - Street 1:4419 FRONTIER TRL STE 101
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1567
Practice Address - Country:US
Practice Address - Phone:512-766-2649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1233729261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy