Healthcare Provider Details

I. General information

NPI: 1295942068
Provider Name (Legal Business Name): BECKY RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 BROWN RD
MANGHAM LA
71259-5144
US

IV. Provider business mailing address

153 BROWN RD
MANGHAM LA
71259-5144
US

V. Phone/Fax

Practice location:
  • Phone: 318-791-6169
  • Fax:
Mailing address:
  • Phone: 318-791-6169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberLA20253
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: