Provider Demographics
NPI:1487863403
Name:RUSSELL, TIMOTHY LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E 3RD ST
Mailing Address - Street 2:SUITE G-100
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2201
Mailing Address - Country:US
Mailing Address - Phone:423-643-1965
Mailing Address - Fax:423-643-2030
Practice Address - Street 1:1100 E 3RD ST
Practice Address - Street 2:SUITE G-100
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2201
Practice Address - Country:US
Practice Address - Phone:423-643-1965
Practice Address - Fax:423-643-2030
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMT173225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist