MEDICARE: MRS. SHANNON LOUISE RUSSELL PT, DPT

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	261QP2000X	Physical Therapy Clinic/Center	1233729	TX

General Provider Information

NPI Number	:	1346647351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANNON LOUISE RUSSELL PT, DPT

Provider Business Mailing Address
First Line	:	4419 FRONTIER TRL STE 101
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-1567
Country	:	US
Telephone Number	:	512-766-2649
Fax Number	:

Provider Business Practice Location Address
First Line	:	4419 FRONTIER TRL STE 101
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-1567
Country	:	US
Telephone Number	:	512-766-2649
Fax Number	:

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

Provider Enumeration Date	:	11/20/2014
Last Update Date	:	11/17/2022

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Directions to “ MRS. SHANNON LOUISE RUSSELL PT, DPT” Practice Location

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