Provider Demographics
NPI:1891256277
Name:LOCKE, RUSSELL LAMAR SR (COTA/L)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LAMAR
Last Name:LOCKE
Suffix:SR
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6511 JUNE DR
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-2326
Mailing Address - Country:US
Mailing Address - Phone:321-333-2068
Mailing Address - Fax:321-877-1027
Practice Address - Street 1:1705 JESS PARRISH CT
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2158
Practice Address - Country:US
Practice Address - Phone:321-269-5720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10650224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant