Provider Demographics
NPI:1902533607
Name:RUSSELL, KATHRYN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 W CHIMNEY ROCK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-2790
Mailing Address - Country:US
Mailing Address - Phone:480-321-5433
Mailing Address - Fax:
Practice Address - Street 1:3900 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6647
Practice Address - Country:US
Practice Address - Phone:916-481-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ324502251X0800X
CA303967225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic