Provider Demographics
NPI:1669118527
Name:RUSSELL, JULIE M (CPTA)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2912 R RD
Mailing Address - Street 2:
Mailing Address - City:HAVILAND
Mailing Address - State:KS
Mailing Address - Zip Code:67059-4718
Mailing Address - Country:US
Mailing Address - Phone:620-770-0490
Mailing Address - Fax:
Practice Address - Street 1:4801 10TH ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3252
Practice Address - Country:US
Practice Address - Phone:620-792-7868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01047225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant