Provider Demographics
NPI:1508083155
Name:RUSSELL, SUSANNE MARIE (MSPT)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 MOLLIFIELD LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-7211
Mailing Address - Country:US
Mailing Address - Phone:434-973-9447
Mailing Address - Fax:
Practice Address - Street 1:3450 SEMINOLE TRL STE 105
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-2210
Practice Address - Country:US
Practice Address - Phone:434-974-7955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003603225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist