Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 856 | NE |
NPI | 1003180472 |
---|---|
Provider Name | Miss Berkeley R Russ |
First Address | Lincoln, NE 68506-4964 |
Second Address | Tecumseh, NE 68450-2069 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/03/2012 |
Last Update Date | 02/03/2012 |