Provider Demographics
NPI:1245058072
Name:RUSSO, GRACE JEWELL (PT, DPT)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:JEWELL
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 148TH CT NE
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-5601
Mailing Address - Country:US
Mailing Address - Phone:816-654-4708
Mailing Address - Fax:
Practice Address - Street 1:1821 HILLANDALE RD STE 25B
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2671
Practice Address - Country:US
Practice Address - Phone:919-660-6628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist