Provider Demographics
NPI:1336699651
Name:RUSSELL, CECILIA (RCR)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RCR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 GOBBLER CT
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-7429
Mailing Address - Country:US
Mailing Address - Phone:270-791-3397
Mailing Address - Fax:270-935-5299
Practice Address - Street 1:207 GOBBLER CT
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-7429
Practice Address - Country:US
Practice Address - Phone:270-791-3397
Practice Address - Fax:270-935-5299
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9804744173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist