Healthcare Provider Details

I. General information

NPI: 1033471545
Provider Name (Legal Business Name): SARAH RUTH RUSSELL LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W LINCOLN AVE
CASEYVILLE IL
62232-1306
US

IV. Provider business mailing address

270 CIRCLE DR
FAIRVIEW HEIGHTS IL
62208-3302
US

V. Phone/Fax

Practice location:
  • Phone: 618-344-9355
  • Fax: 618-344-9356
Mailing address:
  • Phone: 618-398-1063
  • Fax: 618-344-9356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160003016
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: