Healthcare Provider Details

I. General information

NPI: 1225698210
Provider Name (Legal Business Name): ALEX W RUSSELL PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 09/01/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N WALTON BLVD STE 2
BENTONVILLE AR
72712-4548
US

IV. Provider business mailing address

9 MAY LN
BELLA VISTA AR
72715-4804
US

V. Phone/Fax

Practice location:
  • Phone: 479-250-9838
  • Fax:
Mailing address:
  • Phone: 505-917-3911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1324750
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5503
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5415
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: