Individual
MR. EDWARD JOHN RUSSELL III
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
COTAL
Contact information
Practice address
5358 E BASELINE RD, MESA, AZ 85206-4716
(480) 630-3005
Mailing address
25117 SW PARKWAY AVE STE D, WILSONVILLE, OR 97070-9697
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
5776
AZ
Other
Enumeration date
05/06/2014
Last updated
05/06/2014
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