Provider Demographics
NPI:1891942082
Name:PHILLIPPO, RUSSELL JOHN (COTA)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:JOHN
Last Name:PHILLIPPO
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 E 106TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-1325
Mailing Address - Country:US
Mailing Address - Phone:317-460-3493
Mailing Address - Fax:
Practice Address - Street 1:407 E 106TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-1325
Practice Address - Country:US
Practice Address - Phone:317-460-3493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000325A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant