Provider Demographics
NPI:1962656561
Name:GARRISON, RUSSELL (PT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:GARRISON
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 1:80 DENSLOW RD
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-3103
Mailing Address - Country:US
Mailing Address - Phone:413-526-9969
Mailing Address - Fax:413-526-9960
Practice Address - Street 1:80 DENSLOW RD
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-3103
Practice Address - Country:US
Practice Address - Phone:413-526-9969
Practice Address - Fax:413-526-9960
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA28117OtherHEALTH NEW ENGLAND
MA043527497OtherPIONEER
103355100OtherDEPT OF LABOR
MA043527497OtherGREATWEST
MA043527497OtherGIC/UNICARE
MA043527497OtherAETNA
MA690675OtherTUFTS
MA000000035264OtherBMC
MA043527497OtherCONSOLIDATED
MA972730OtherNETWOTK HEALTH
MA043527OtherCONNECTICARE
MA9715568Medicaid
MA043527497OtherNORTH REGIONS
MA043527497OtherCIGNA
MA043527497OtherUNITED HEALTHCARE
MAPT0191Medicare PIN