Provider Demographics
NPI:1578043873
Name:RUSSELL, KARLIE
Entity Type:Individual
Prefix:
First Name:KARLIE
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:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:OH
Mailing Address - Zip Code:43906
Mailing Address - Country:US
Mailing Address - Phone:740-325-1120
Mailing Address - Fax:740-325-1743
Practice Address - Street 1:3050 GUERNSEY STREET
Practice Address - Street 2:SUITE B
Practice Address - City:BELLAIRE
Practice Address - State:OH
Practice Address - Zip Code:43906
Practice Address - Country:US
Practice Address - Phone:740-325-1120
Practice Address - Fax:740-325-1743
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011957225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist