Provider Demographics
NPI:1699343558
Name:RUSSELL, MICHELE RENAE (DPT)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:RENAE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:RENAE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-0658
Mailing Address - Country:US
Mailing Address - Phone:928-242-0821
Mailing Address - Fax:
Practice Address - Street 1:4830 HIGHWAY 260 STE 105
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5851
Practice Address - Country:US
Practice Address - Phone:928-532-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist