Provider Demographics
NPI:1801401781
Name:GREEN, RUSSELL THOMAS (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:THOMAS
Last Name:GREEN
Suffix:
Gender:M
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 1:18252 FM 1488 RD STE 130
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-4527
Mailing Address - Country:US
Mailing Address - Phone:281-356-8645
Mailing Address - Fax:
Practice Address - Street 1:18252 FM 1488 RD STE 130
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-4527
Practice Address - Country:US
Practice Address - Phone:281-356-8645
Practice Address - Fax:281-356-8447
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1314993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist