Provider Demographics
NPI:1215155932
Name:RUSSELL, GAIL MARIA (OTR)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:MARIA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 S SUMMERTREE RD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4023
Mailing Address - Country:US
Mailing Address - Phone:714-637-5123
Mailing Address - Fax:
Practice Address - Street 1:1800 E LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2902
Practice Address - Country:US
Practice Address - Phone:714-633-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1762225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist