Basic Information
| Provider Information | |||||||||
| NPI: | 1720568819 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | ODELL | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 419 S ELM ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762016085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003455603 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3600 ANGLE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761063559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176246164 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2018 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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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 | 225200000X | 2035186 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.