Provider Demographics
NPI:1376241869
Name:SELIGMAN-RUSSO, LARA ANN (DPT)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:ANN
Last Name:SELIGMAN-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 1:755 MEMORIAL PKWY STE 208
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-2773
Mailing Address - Country:US
Mailing Address - Phone:908-847-6756
Mailing Address - Fax:
Practice Address - Street 1:755 MEMORIAL PKWY STE 208
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-2773
Practice Address - Country:US
Practice Address - Phone:908-847-6756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA020619002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA02061900OtherSTATE