Provider Demographics
NPI:1518381268
Name:RUSSELL, PHYLLIS (LMT)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 E MONTGOMERY XRD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4980
Mailing Address - Country:US
Mailing Address - Phone:912-925-0881
Mailing Address - Fax:
Practice Address - Street 1:407 E MONTGOMERY XRD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4980
Practice Address - Country:US
Practice Address - Phone:912-925-0881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009487225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist