Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | OT4456 | NM |
NPI | 1194390963 |
---|---|
Provider Name | Ms. Julie Laine Russell |
First Address | Albuquerque, NM 87111-7317 |
Second Address | Albuquerque, NM 87114-5201 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2021 |
Last Update Date | 24/05/2021 |