Basic Information
| Provider Information | |||||||||
| NPI: | 1578875563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL-CANAAN | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3179 BRAVERTON ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | EDGEWATER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210372667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007935464 | ||||||||
| FaxNumber: | 2673212099 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 N ROLLING RD | ||||||||
| Address2: | STE 302 | ||||||||
| City: | CATONSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212284140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107441666 | ||||||||
| FaxNumber: | 4107889755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 23328 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.