Provider Demographics
NPI:1770815607
Name:CHILDERS, RUSSELL WILLIAM II (PT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WILLIAM
Last Name:CHILDERS
Suffix:II
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 NEEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02464-1595
Mailing Address - Country:US
Mailing Address - Phone:713-443-5939
Mailing Address - Fax:
Practice Address - Street 1:244 NEEDHAM ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464-1595
Practice Address - Country:US
Practice Address - Phone:713-443-5939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20041225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist