Provider Demographics
NPI:1902161672
Name:SUSY RUSSELL PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SUSY RUSSELL PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:434-249-9578
Mailing Address - Street 1:3040 BERKMAR DR STE A1
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1593
Mailing Address - Country:US
Mailing Address - Phone:434-249-9578
Mailing Address - Fax:
Practice Address - Street 1:3040 BERKMAR DR STE A1
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-1593
Practice Address - Country:US
Practice Address - Phone:434-249-9578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003603261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy