Provider Demographics
NPI:1548323090
Name:RUSSELL, DENNIS MICHEAL (ATC, NRP)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:MICHEAL
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:ATC, NRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5435
Mailing Address - Country:US
Mailing Address - Phone:207-777-6006
Mailing Address - Fax:
Practice Address - Street 1:192 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5435
Practice Address - Country:US
Practice Address - Phone:207-777-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2014-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME20114146L00000X
MEAT1392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic