Provider Demographics
NPI:1639694490
Name:CARR, RUSSELL WAYNE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WAYNE
Last Name:CARR
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-8930
Mailing Address - Fax:423-254-5217
Practice Address - Street 1:1704 E STONE DR STE 120
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4679
Practice Address - Country:US
Practice Address - Phone:423-765-0985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-13
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013054225100000X
TN12261225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist