Provider Demographics
NPI:1922493055
Name:RUSSELL, GEORGE (PT)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:RUSSELL
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 1:12961 LAFAYETTE ST UNIT H
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80241-3969
Mailing Address - Country:US
Mailing Address - Phone:720-508-3422
Mailing Address - Fax:
Practice Address - Street 1:12961 LAFAYETTE ST UNIT H
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80241-3969
Practice Address - Country:US
Practice Address - Phone:720-508-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL0012394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist