Provider Demographics
NPI:1710747720
Name:RUSSECK, NICOLE (LMT, CLT, HTP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RUSSECK
Suffix:
Gender:F
Credentials:LMT, CLT, HTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CYNWYD DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-2357
Mailing Address - Country:US
Mailing Address - Phone:267-614-1921
Mailing Address - Fax:
Practice Address - Street 1:701 HYDE PARK
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18902-6612
Practice Address - Country:US
Practice Address - Phone:267-614-1921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG009326225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist