Healthcare Provider Details

I. General information

NPI: 1225126394
Provider Name (Legal Business Name): ELIZABETH RUSSEL PHD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 S SPRING ST SUITE 01-11
LOS ANGELES CA
90013-1211
US

IV. Provider business mailing address

1923 W PARKSIDE AVE
BURBANK CA
91506-2910
US

V. Phone/Fax

Practice location:
  • Phone: 213-897-6345
  • Fax: 213-897-2882
Mailing address:
  • Phone: 818-841-0997
  • Fax: 818-841-0997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberBOT 295
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: