Individual
VICTORIA LYN RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
6884 HICKORY FLAT HWY, WOODSTOCK, GA 30188-3229
(770) 704-8244
(770) 704-8264
Mailing address
285 OLD DAWSONVILLE RD, BALL GROUND, GA 30107-2931
(678) 454-1044
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
003654
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
511G701183
MEDICARE GROUP
GA
Enumeration date
05/02/2007
Last updated
04/15/2016
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