Provider Demographics
NPI:1700841038
Name:RUSSELL, IDA ALICIA (ATC)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:ALICIA
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 1:3408 SILICA HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-5622
Mailing Address - Country:US
Mailing Address - Phone:501-860-6601
Mailing Address - Fax:
Practice Address - Street 1:424 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3109
Practice Address - Country:US
Practice Address - Phone:501-661-0336
Practice Address - Fax:501-661-0412
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer