Individual
MR. KEVIN T RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
BS, MSPT
Contact information
Practice address
111 GOOSE LANE, STE 2500, GUILFORD, CT 06437
(203) 453-0134
(203) 453-0167
Mailing address
111 GOOSE LANE, SUITE 2500, GUILFORD, CT 06437
(203) 453-0134
(203) 453-0167
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
4359
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004133906
—
CT
01
—
080004359CT04
BLUE CROSS BLUE SHEILD
CT
Enumeration date
08/01/2006
Last updated
03/23/2012
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