Provider Demographics
NPI:1104969336
Name:DE LAP, RUSSELL DONALD (ATC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:DONALD
Last Name:DE LAP
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 TOWER HILL DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-6705
Mailing Address - Country:US
Mailing Address - Phone:262-789-5040
Mailing Address - Fax:
Practice Address - Street 1:12800 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2418
Practice Address - Country:US
Practice Address - Phone:262-243-4323
Practice Address - Fax:262-243-2969
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer