Healthcare Provider Details

I. General information

NPI: 1124220082
Provider Name (Legal Business Name): GAIL LYN RUSSELL LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5224 N. 200TH ST
OBLONG IL
62449
US

IV. Provider business mailing address

1000 N ALLEN ST
ROBINSON IL
62454-1167
US

V. Phone/Fax

Practice location:
  • Phone: 618-592-6353
  • Fax: 618-546-2635
Mailing address:
  • Phone: 618-544-3131
  • Fax: 618-546-2635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: