Provider Demographics
NPI:1689673410
Name:RUSSELL, HOLLY ROXANNE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ROXANNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 COUNTY ROAD 1435 N
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-4827
Mailing Address - Country:US
Mailing Address - Phone:618-382-3986
Mailing Address - Fax:618-382-3986
Practice Address - Street 1:2907 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5256
Practice Address - Country:US
Practice Address - Phone:618-998-9894
Practice Address - Fax:618-998-9993
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
606640Medicare ID - Type Unspecified