Healthcare Provider Details

I. General information

NPI: 1285918052
Provider Name (Legal Business Name): HOLLY RUSSELL MS, OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10320 N NEW JERSEY ST
INDIANAPOLIS IN
46280-1360
US

IV. Provider business mailing address

10320 N NEW JERSEY ST
INDIANAPOLIS IN
46280-1360
US

V. Phone/Fax

Practice location:
  • Phone: 317-413-5778
  • Fax:
Mailing address:
  • Phone: 317-413-5778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number06720
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number31003599A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: