Provider Demographics
NPI:1992718837
Name:RUSSELL, KIMBERLY J (PT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 MONUMENT STREET
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272
Mailing Address - Country:US
Mailing Address - Phone:310-573-9553
Mailing Address - Fax:310-573-9533
Practice Address - Street 1:135 S BARRINGTON PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-3305
Practice Address - Country:US
Practice Address - Phone:310-472-2121
Practice Address - Fax:310-472-4567
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6220035-2401225100000X
CA357092251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACN474ZMedicare UPIN