Provider Demographics
NPI:1144837170
Name:RUSSELL, ANDERSON (PT,DPT)
Entity type:Individual
Prefix:
First Name:ANDERSON
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
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 1:404 WASHINGTON AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-6651
Mailing Address - Country:US
Mailing Address - Phone:305-479-2973
Mailing Address - Fax:305-735-7662
Practice Address - Street 1:404 WASHINGTON AVE STE 120
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-6651
Practice Address - Country:US
Practice Address - Phone:305-479-2973
Practice Address - Fax:305-735-7662
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT36374225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty