Provider Demographics
NPI:1255149753
Name:RUSSELL, RANDALL LOYD (PT)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:LOYD
Last Name:RUSSELL
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 1:13 NORTHTOWN DR STE 110
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3047
Mailing Address - Country:US
Mailing Address - Phone:601-206-9195
Mailing Address - Fax:601-957-8391
Practice Address - Street 1:5958 SAINT BERNARD AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70122-1324
Practice Address - Country:US
Practice Address - Phone:601-206-9195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist