Provider Demographics
NPI:1477858744
Name:RUSSELL, JUDITH ANN (COTA/C)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:COTA/C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2603
Mailing Address - Country:US
Mailing Address - Phone:716-692-1801
Mailing Address - Fax:
Practice Address - Street 1:2495 MAIN ST
Practice Address - Street 2:SUITE 234
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2152
Practice Address - Country:US
Practice Address - Phone:716-836-5929
Practice Address - Fax:716-836-6057
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005258-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant