Provider Demographics
NPI:1780767202
Name:RUSSELL, NAOMI LYNN (LMP CCT)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMP CCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 1ST AVENUE SOUTH
Mailing Address - Street 2:#2B
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104
Mailing Address - Country:US
Mailing Address - Phone:206-954-5450
Mailing Address - Fax:
Practice Address - Street 1:915 EAST PINE STREET
Practice Address - Street 2:SUITE 420
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112
Practice Address - Country:US
Practice Address - Phone:206-954-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020643225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist