Provider Demographics
NPI:1992091763
Name:RUSSELL, LAUREN K (PT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:K
Last Name:RUSSELL
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 412307
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2307
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:
Practice Address - Street 1:680 KINGSBOROUGH SQ STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4988
Practice Address - Country:US
Practice Address - Phone:757-547-0434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23658225100000X
VA2305213238225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist