Provider Demographics
NPI:1598702615
Name:WARREN, RUSSELL J (PT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:WARREN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 YAPHANK MIDDLE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11980-9703
Mailing Address - Country:US
Mailing Address - Phone:631-775-7693
Mailing Address - Fax:
Practice Address - Street 1:472 YAPHANK MIDDLE ISLAND RD
Practice Address - Street 2:
Practice Address - City:YAPHANK
Practice Address - State:NY
Practice Address - Zip Code:11980-9703
Practice Address - Country:US
Practice Address - Phone:631-775-7693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist