Basic Information
| Provider Information | |||||||||
| NPI: | 1487863403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 E 3RD ST | ||||||||
| Address2: | SUITE G-100 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236431965 | ||||||||
| FaxNumber: | 4236432030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 E 3RD ST | ||||||||
| Address2: | SUITE G-100 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236431965 | ||||||||
| FaxNumber: | 4236432030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MT173 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.