Provider Demographics
NPI:1063126902
Name:RUSSU, TIMOTHY MATTEO
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MATTEO
Last Name:RUSSU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DOVER ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-1274
Mailing Address - Country:US
Mailing Address - Phone:720-625-1667
Mailing Address - Fax:
Practice Address - Street 1:12380 W 64TH AVE
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004-4016
Practice Address - Country:US
Practice Address - Phone:303-467-5337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019104225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist