Provider Demographics
NPI:1649882424
Name:RUSSELL, SHEA-RACQUEL
Entity type:Individual
Prefix:MISS
First Name:SHEA-RACQUEL
Middle Name:
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 1:807 APRICOT DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-2413
Mailing Address - Country:US
Mailing Address - Phone:407-520-9984
Mailing Address - Fax:
Practice Address - Street 1:807 APRICOT DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-2413
Practice Address - Country:US
Practice Address - Phone:407-520-9984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL93523225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist