Provider Demographics
NPI:1851449185
Name:MASSEY, RUSSELL W (PT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:W
Last Name:MASSEY
Suffix:
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 1:100 OLD CHEROKEE RD
Mailing Address - Street 2:PMB 310
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9316
Mailing Address - Country:US
Mailing Address - Phone:803-920-6349
Mailing Address - Fax:
Practice Address - Street 1:100 OLD CHEROKEE RD
Practice Address - Street 2:PMB 310
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9316
Practice Address - Country:US
Practice Address - Phone:803-920-6349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC958225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC958OtherLICENSE #