Provider Demographics
NPI:1770329328
Name:RUSSELL, NICOLE DIANE (PT, DPT, CWS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:DIANE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT, DPT, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BALCONES DR # 23130
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4257
Mailing Address - Country:US
Mailing Address - Phone:512-569-4110
Mailing Address - Fax:
Practice Address - Street 1:727 ANTHEM LN
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78132-5330
Practice Address - Country:US
Practice Address - Phone:512-569-4110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1279928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty