Provider Demographics
NPI:1124851803
Name:ALLEN, RUSSELL CARROLL JR (PT, DPT)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:CARROLL
Last Name:ALLEN
Suffix:JR
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 1:174 FLETCHER RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-8874
Mailing Address - Country:US
Mailing Address - Phone:207-577-4142
Mailing Address - Fax:
Practice Address - Street 1:690 MINOT AVE STE 2
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-3922
Practice Address - Country:US
Practice Address - Phone:207-753-3456
Practice Address - Fax:207-782-9000
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT6934225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist