Provider Demographics
NPI:1720568819
Name:RUSSELL, TRAVIS ODELL JR (PTA)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ODELL
Last Name:RUSSELL
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-6085
Mailing Address - Country:US
Mailing Address - Phone:800-345-5603
Mailing Address - Fax:
Practice Address - Street 1:3600 ANGLE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76106-3559
Practice Address - Country:US
Practice Address - Phone:817-624-6164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2035186225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant