Provider Demographics
NPI:1821767690
Name:RUSSELL, MARLY L (PTA)
Entity Type:Individual
Prefix:
First Name:MARLY
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MARLY
Other - Middle Name:L
Other - Last Name:JINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31 CHOCTAW CENTER
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:72529
Mailing Address - Country:US
Mailing Address - Phone:870-856-4325
Mailing Address - Fax:870-856-4327
Practice Address - Street 1:31 CHOCTAW CENTER
Practice Address - Street 2:
Practice Address - City:CHEROKEE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:72529
Practice Address - Country:US
Practice Address - Phone:870-856-4325
Practice Address - Fax:870-856-4327
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA4613225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant