Provider Demographics
NPI:1679793038
Name:RUSSELL, SONEA MARIA (PTA)
Entity type:Individual
Prefix:MRS
First Name:SONEA
Middle Name:MARIA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1659 DOC MCLOCKLIN RD
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-2521
Mailing Address - Country:US
Mailing Address - Phone:770-725-0659
Mailing Address - Fax:
Practice Address - Street 1:WILLOWOOD NURSING CENTER
Practice Address - Street 2:4595 CANTRELL ROAD
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542
Practice Address - Country:US
Practice Address - Phone:770-965-1484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001984225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant