Provider Demographics
NPI:1578875563
Name:RUSSELL-CANAAN, CAROLYN ELAINE (DPT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ELAINE
Last Name:RUSSELL-CANAAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3179 BRAVERTON ST
Mailing Address - Street 2:STE 201
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-2667
Mailing Address - Country:US
Mailing Address - Phone:800-793-5464
Mailing Address - Fax:267-321-2099
Practice Address - Street 1:516 N ROLLING RD
Practice Address - Street 2:STE 302
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4140
Practice Address - Country:US
Practice Address - Phone:410-744-1666
Practice Address - Fax:410-788-9755
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MD23328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist