Basic Information
| Provider Information | |||||||||
| NPI: | 1891250379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | MEI | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11525 COMMUNITY CENTER DR APT I307 | ||||||||
| Address2: | |||||||||
| City: | NORTHGLENN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802331123 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9195 GRANT ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802294386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034532997 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2019 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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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 | 2255A2300X | AT.0001967 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.