Provider Demographics
NPI:1679350607
Name:RUSSELL, FORREST (DPT)
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:4650 HUGH HOWELL RD STE 270
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5035
Practice Address - Country:US
Practice Address - Phone:470-857-3606
Practice Address - Fax:470-777-4258
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist