Provider Demographics
NPI:1255741724
Name:RUSSELL, LORI RENE (OT)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:RENE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:RENE
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1200 B GALE WILSON BLVD
Mailing Address - Street 2:ATTN: REHAB DEPARTMENT
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3552
Mailing Address - Country:US
Mailing Address - Phone:707-624-7470
Mailing Address - Fax:
Practice Address - Street 1:2500 HILBORN RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-1097
Practice Address - Country:US
Practice Address - Phone:707-646-5599
Practice Address - Fax:707-646-5574
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA438225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist