Provider Demographics
NPI:1548399223
Name:RUSSELL, CHASTITY FAITH (OTR)
Entity Type:Individual
Prefix:MRS
First Name:CHASTITY
Middle Name:FAITH
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 1:121 LOGAN RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40069-9694
Mailing Address - Country:US
Mailing Address - Phone:859-336-9498
Mailing Address - Fax:859-336-7089
Practice Address - Street 1:121 LOGAN RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:KY
Practice Address - Zip Code:40069-9694
Practice Address - Country:US
Practice Address - Phone:859-336-9498
Practice Address - Fax:859-336-7089
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKYR2779225X00000X
KY133179225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist