Provider Demographics
NPI:1760724389
Name:RUSSELL, BETHANY ZYLSTRA COLEMAN (OT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ZYLSTRA COLEMAN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 CHILDRENS WAY # MC5068
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:588-966-8100
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDRENS WAY # MC5068
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-966-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60329439225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist