Healthcare Provider Details

I. General information

NPI: 1265753495
Provider Name (Legal Business Name): BILLIE CHERIE RUSSELL LCMT.MMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3735 G RD
PALISADE CO
81526-8613
US

IV. Provider business mailing address

3735 G RD
PALISADE CO
81526-8613
US

V. Phone/Fax

Practice location:
  • Phone: 970-250-9365
  • Fax:
Mailing address:
  • Phone: 970-250-9365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2423
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: