Provider Demographics
NPI:1316490113
Name:RUSSELL, THOMAS (PT, DPT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:RUSSELL
Suffix:
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 1:380 STEVENS AVE
Mailing Address - Street 2:SUITE 314
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2063
Mailing Address - Country:US
Mailing Address - Phone:858-755-5200
Mailing Address - Fax:
Practice Address - Street 1:380 STEVENS AVE
Practice Address - Street 2:SUITE 314
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2063
Practice Address - Country:US
Practice Address - Phone:858-755-5200
Practice Address - Fax:858-755-5201
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292213225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation