Provider Demographics
NPI:1053158253
Name:RUSSELL, KURT MICHAEL
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:MICHAEL
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 RYAN CIR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-2313
Mailing Address - Country:US
Mailing Address - Phone:601-549-4098
Mailing Address - Fax:
Practice Address - Street 1:98 JEFF DAVIS AVE STE B
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-6172
Practice Address - Country:US
Practice Address - Phone:228-313-9208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3806225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist