Healthcare Provider Details

I. General information

NPI: 1558836759
Provider Name (Legal Business Name): RUSSELL EVANS WHITNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 VICTORY PKWY
CINCINNATI OH
45206-1754
US

IV. Provider business mailing address

11651 NORBOURNE DR APT 915
CINCINNATI OH
45240-4458
US

V. Phone/Fax

Practice location:
  • Phone: 513-221-4673
  • Fax:
Mailing address:
  • Phone: 513-888-4037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: