Healthcare Provider Details

I. General information

NPI: 1922580380
Provider Name (Legal Business Name): ALI RENEE RUSSELL LMT, CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2018
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 W 2ND ST STE 200
GRAND ISLAND NE
68803-5463
US

IV. Provider business mailing address

1118 W 11TH ST
GRAND ISLAND NE
68801-4018
US

V. Phone/Fax

Practice location:
  • Phone: 308-289-6370
  • Fax:
Mailing address:
  • Phone: 308-289-6370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3592
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: