Provider Demographics
NPI:1306540810
Name:RUSSELL, TIMMIE EMIL II
Entity type:Individual
Prefix:
First Name:TIMMIE
Middle Name:EMIL
Last Name:RUSSELL
Suffix:II
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 1:21606 TEA TREE OLIVE PL
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-6572
Mailing Address - Country:US
Mailing Address - Phone:281-768-9087
Mailing Address - Fax:
Practice Address - Street 1:21606 TEA TREE OLIVE PL
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:TX
Practice Address - Zip Code:77365-6572
Practice Address - Country:US
Practice Address - Phone:281-768-9087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer