Healthcare Provider Details

I. General information

NPI: 1376318196
Provider Name (Legal Business Name): FAITH ANASTASIA RUSSELL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16968 W BELL RD STE D-410
SURPRISE AZ
85374-8943
US

IV. Provider business mailing address

14287 N 87TH ST STE 220
SCOTTSDALE AZ
85260-3698
US

V. Phone/Fax

Practice location:
  • Phone: 632-299-9190
  • Fax:
Mailing address:
  • Phone: 480-937-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12120
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP026179T
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: