Provider Demographics
NPI:1720331820
Name:TRUSSELL, KATIE M (OT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 JACKSBORO PIKE STE 2
Mailing Address - Street 2:
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-2908
Mailing Address - Country:US
Mailing Address - Phone:423-566-2250
Mailing Address - Fax:423-563-5873
Practice Address - Street 1:2435 JACKSBORO PIKE STE 2
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2908
Practice Address - Country:US
Practice Address - Phone:423-566-2250
Practice Address - Fax:423-563-5873
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5574225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist