Provider Demographics
NPI:1598199606
Name:RUSSELL, ABBY GRACE (DPT)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:GRACE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:GRACE
Other - Last Name:COMEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1377
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-1377
Mailing Address - Country:US
Mailing Address - Phone:318-396-1969
Mailing Address - Fax:318-396-1970
Practice Address - Street 1:107 SUMMER LN
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-3501
Practice Address - Country:US
Practice Address - Phone:318-396-1969
Practice Address - Fax:318-396-1970
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA8632OtherPT LICENSE