Provider Demographics
NPI:1780035881
Name:RUSSELL, ELISABETH MARIE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8219 SOLANO BAY LOOP
Mailing Address - Street 2:APT 1033
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-9573
Mailing Address - Country:US
Mailing Address - Phone:585-281-4754
Mailing Address - Fax:
Practice Address - Street 1:4107 N HIMES AVE
Practice Address - Street 2:STE 110
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6655
Practice Address - Country:US
Practice Address - Phone:813-874-1009
Practice Address - Fax:813-872-6717
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist