Provider Demographics
NPI:1568082923
Name:RUSSELL, CARISSA LEIGH (ATC)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:LEIGH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 S MAIN ST APT D4
Mailing Address - Street 2:
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840-1055
Mailing Address - Country:US
Mailing Address - Phone:989-430-9977
Mailing Address - Fax:
Practice Address - Street 1:28080 LEMOYNE RD
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:OH
Practice Address - Zip Code:43447-9747
Practice Address - Country:US
Practice Address - Phone:419-279-3794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer