Provider Demographics
NPI:1457069874
Name:RUSSELL, CAROL HOXIE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:HOXIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2649 JAMES ST STE 106
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-2801
Mailing Address - Country:US
Mailing Address - Phone:315-412-6630
Mailing Address - Fax:
Practice Address - Street 1:2649 JAMES ST STE 106
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-2801
Practice Address - Country:US
Practice Address - Phone:315-412-6630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024623225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist