Provider Demographics
NPI:1851756662
Name:RUSS, MARY ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:RUSS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PERCHERON DR
Mailing Address - Street 2:
Mailing Address - City:SPRING CITY
Mailing Address - State:PA
Mailing Address - Zip Code:19475-2609
Mailing Address - Country:US
Mailing Address - Phone:610-792-4567
Mailing Address - Fax:
Practice Address - Street 1:11 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:SPRING CITY
Practice Address - State:PA
Practice Address - Zip Code:19475-1239
Practice Address - Country:US
Practice Address - Phone:610-948-0981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE005262L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant