Provider Demographics
NPI:1225672637
Name:RUSSELL, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:PERRYSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47974
Mailing Address - Country:US
Mailing Address - Phone:812-201-7403
Mailing Address - Fax:
Practice Address - Street 1:420 GREEN ST
Practice Address - Street 2:
Practice Address - City:PERRYSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47974
Practice Address - Country:US
Practice Address - Phone:812-201-7403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.021427225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist