Provider Demographics
NPI:1225698210
Name:RUSSELL, ALEX W (PT, DPT, CSCS)
Entity Type:Individual
Prefix:MR
First Name:ALEX
Middle Name:W
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2668 E CITIZENS DR STE 5
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4796
Mailing Address - Country:US
Mailing Address - Phone:479-442-7473
Mailing Address - Fax:479-239-5444
Practice Address - Street 1:5320 W SUNSET AVE STE 168
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-4410
Practice Address - Country:US
Practice Address - Phone:479-364-6467
Practice Address - Fax:479-239-5444
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5503225100000X
TX1324750225100000X
ARPT5415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist