MEDICARE: MR. WELDON K RUSSO OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	109622	TX

General Provider Information

NPI Number	:	1093918989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WELDON K RUSSO OTR

Provider Business Mailing Address
First Line	:	7277 HAWKINS VIEW DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3921
Country	:	US
Telephone Number	:	817-423-5611
Fax Number	:	817-423-5577

Provider Business Practice Location Address
First Line	:	7277 HAWKINS VIEW DRIVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3921
Country	:	US
Telephone Number	:	817-423-5611
Fax Number	:	817-423-5577

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	09/17/2009

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