MEDICARE: MS. ELIZABETH RUSSEL PHD, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	BOT 295	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CTO 002950	OTHER	CA	MEDI-CAL NUMBER
2	CMS 165416	OTHER	CA	CHILDREN'S MEDICAL SERVIC
3	OT 295	OTHER	CA	BOARD OF OCCUPATIONAL THE

General Provider Information

NPI Number	:	1225126394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELIZABETH RUSSEL PHD, OTR/L

Provider Business Mailing Address
First Line	:	1923 W PARKSIDE AVE
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91506-2910
Country	:	US
Telephone Number	:	818-841-0997
Fax Number	:	818-841-0997

Provider Business Practice Location Address
First Line	:	311 S SPRING ST
Second Line	:	SUITE 01-11
City	:	LOS ANGELES
State	:	CA
Zip	:	90013-1211
Country	:	US
Telephone Number	:	213-897-6345
Fax Number	:	213-897-2882

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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