Provider Demographics
NPI:1508088584
Name:RUSSELL, VICTORIA LYN
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 OLD DAWSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-2931
Mailing Address - Country:US
Mailing Address - Phone:678-454-1044
Mailing Address - Fax:
Practice Address - Street 1:6884 HICKORY FLAT HWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3229
Practice Address - Country:US
Practice Address - Phone:770-704-8244
Practice Address - Fax:770-704-8264
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003654225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G701183OtherMEDICARE GROUP