Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 292213 | CA |
NPI | 1316490113 |
---|---|
Provider Name | Thomas Russell |
First Address | Solana Beach, CA 92075-2063 |
Second Address | Solana Beach, CA 92075-2063 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2016 |
Last Update Date | 07/11/2016 |