Provider Demographics
NPI:1629512835
Name:RUSSELL, LORI YOUNGER (CERT HAIR LOSS SPEC)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:YOUNGER
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CERT HAIR LOSS SPEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 HYDEN PL
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4435
Mailing Address - Country:US
Mailing Address - Phone:571-230-6302
Mailing Address - Fax:
Practice Address - Street 1:6133 BACKLICK RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2637
Practice Address - Country:US
Practice Address - Phone:571-230-6302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12040182221744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management