Provider Demographics
NPI:1366154155
Name:RUSSELL, SHAUN DOUGLAS (DPT)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:DOUGLAS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16830 VENTURA BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1722
Mailing Address - Country:US
Mailing Address - Phone:818-986-1203
Mailing Address - Fax:
Practice Address - Street 1:16830 VENTURA BLVD STE 150
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1722
Practice Address - Country:US
Practice Address - Phone:818-986-1203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA303246OtherLICENSE NUMBER