Provider Demographics
NPI:1962039131
Name:HOLMES-RUSSELL, LA' SHANDRA (OTR/L)
Entity Type:Individual
Prefix:
First Name:LA' SHANDRA
Middle Name:
Last Name:HOLMES-RUSSELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ELM ST
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-1607
Mailing Address - Country:US
Mailing Address - Phone:401-326-4739
Mailing Address - Fax:
Practice Address - Street 1:15 ELM ST
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-1607
Practice Address - Country:US
Practice Address - Phone:401-326-4739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119008569225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist