Provider Demographics
NPI:1881160315
Name:RUSSELL, KATHRYN ANNE (M ED,ATC, LAT, EPC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:M ED,ATC, LAT, EPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 MUSTANG AVE
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-2121
Mailing Address - Country:US
Mailing Address - Phone:832-223-3000
Mailing Address - Fax:
Practice Address - Street 1:4606 MUSTANG AVE
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-2121
Practice Address - Country:US
Practice Address - Phone:832-223-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT77222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer