Provider Demographics
NPI:1245356831
Name:RUSSELL, CYTHTHIA JANE (PT)
Entity type:Individual
Prefix:MS
First Name:CYTHTHIA
Middle Name:JANE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 ARABIAN CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27358-7910
Mailing Address - Country:US
Mailing Address - Phone:336-951-4557
Mailing Address - Fax:336-951-4546
Practice Address - Street 1:618 S MAIN ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5020
Practice Address - Country:US
Practice Address - Phone:336-951-4557
Practice Address - Fax:336-951-4546
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4684225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3400091Medicaid