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General NPI Number Information
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NPI Number | 1235336462
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Entity Type | Individual
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Provider Name | KRISTA RUSSELL PT
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Gender | Female
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Dates
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Enumeration Date | 06/29/2007
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Last Update Date | 11/21/2012
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Provider Practice Location Address
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Address Line | 100 GRAND ST
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City | NEW BRITAIN
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State | CT
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Zip | 06052-2016
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Country | US
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Telephone | 860-224-5121
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Fax |
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Provider Business Mailing Address
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Address Line | 603 CAT TAIL LN
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City | MANCHESTER
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State | CT
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Zip | 06042-7104
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Country | US
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Telephone | 740-374-2107
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 010164
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 005597
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License Number State | CT
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