Provider Demographics
NPI:1750669263
Name:RUSSELL, ASHLYN KALAMA (LMT)
Entity Type:Individual
Prefix:
First Name:ASHLYN
Middle Name:KALAMA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 BORDEAUX AVE
Mailing Address - Street 2:#01-101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-5783
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6201 BORDEAUX AVE
Practice Address - Street 2:#01-101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-5783
Practice Address - Country:US
Practice Address - Phone:808-283-5048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT107391225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist