Provider Demographics
NPI:1700657392
Name:CORCORAN, RUSSELL LEE
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LEE
Last Name:CORCORAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 S WAXBERRY RD
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77381-2836
Mailing Address - Country:US
Mailing Address - Phone:936-291-2582
Mailing Address - Fax:
Practice Address - Street 1:10210 GROGANS MILL RD STE 210
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-1143
Practice Address - Country:US
Practice Address - Phone:936-291-2582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT137891225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist