Provider Demographics
NPI:1992196364
Name:RUSSELL, TEKI MASHAWN (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:TEKI
Middle Name:MASHAWN
Last Name: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 1:20 ELIZABETH RD
Mailing Address - Street 2:
Mailing Address - City:SENOIA
Mailing Address - State:GA
Mailing Address - Zip Code:30276-2524
Mailing Address - Country:US
Mailing Address - Phone:770-599-4500
Mailing Address - Fax:770-599-4500
Practice Address - Street 1:444 CHESTLEHURST RD
Practice Address - Street 2:
Practice Address - City:SENOIA
Practice Address - State:GA
Practice Address - Zip Code:30276-2505
Practice Address - Country:US
Practice Address - Phone:770-599-4500
Practice Address - Fax:770-599-4500
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002684171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor