Provider Demographics
NPI:1194507046
Name:RUSSELL, SKYLAR MARIE (MOT/S)
Entity type:Individual
Prefix:
First Name:SKYLAR
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MOT/S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10640 N RIVERSIDE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-9506
Mailing Address - Country:US
Mailing Address - Phone:817-431-9000
Mailing Address - Fax:
Practice Address - Street 1:111 LARSON LN
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-4589
Practice Address - Country:US
Practice Address - Phone:817-431-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124887225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124887OtherOCCUPATIONAL THERAPY