Provider Demographics
NPI:1538325279
Name:RUSSELL, SARAH NICOLE (OTR)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:NICOLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-1548
Mailing Address - Country:US
Mailing Address - Phone:618-382-4644
Mailing Address - Fax:
Practice Address - Street 1:216 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1548
Practice Address - Country:US
Practice Address - Phone:618-382-4644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007849225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist