Provider Demographics
NPI:1710453824
Name:RUSSELL, ELAINE (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:LAINEY
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:10600 PECK RD
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:OH
Mailing Address - Zip Code:44255-9505
Mailing Address - Country:US
Mailing Address - Phone:330-221-7634
Mailing Address - Fax:
Practice Address - Street 1:10600 PECK RD
Practice Address - Street 2:
Practice Address - City:MANTUA
Practice Address - State:OH
Practice Address - Zip Code:44255-9505
Practice Address - Country:US
Practice Address - Phone:330-221-7634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2221225X00000X
OHOT012568225X00000X
PAOC15836225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist