Provider Demographics
NPI:1881601318
Name:RUSSELL, KEVIN T (BS, MSPT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:T
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:BS, MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 GOOSE LANE
Mailing Address - Street 2:SUITE 2500
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437
Mailing Address - Country:US
Mailing Address - Phone:203-453-0134
Mailing Address - Fax:203-453-0167
Practice Address - Street 1:111 GOOSE LANE
Practice Address - Street 2:STE 2500
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437
Practice Address - Country:US
Practice Address - Phone:203-453-0134
Practice Address - Fax:203-453-0167
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4359225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080004359CT04OtherBLUE CROSS BLUE SHEILD
CT004133906Medicaid
CT004133906Medicaid
CTC03500Medicare PIN