Basic Information
| Provider Information | |||||||||
| NPI: | 1316490113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 STEVENS AVE | ||||||||
| Address2: | SUITE 314 | ||||||||
| City: | SOLANA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920752063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587555200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 380 STEVENS AVE | ||||||||
| Address2: | SUITE 314 | ||||||||
| City: | SOLANA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920752063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587555200 | ||||||||
| FaxNumber: | 8587555201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2016 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0019X | 292213 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation |
No ID Information.