Provider Demographics
NPI:1407989445
Name:RUSSELL, MATTHEW THOMAS (PTA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 673
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-0673
Mailing Address - Country:US
Mailing Address - Phone:845-294-5065
Mailing Address - Fax:
Practice Address - Street 1:3535 HILL BLVD
Practice Address - Street 2:SUITE P
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-1293
Practice Address - Country:US
Practice Address - Phone:914-962-2728
Practice Address - Fax:914-962-1729
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001809-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant