Healthcare Provider Details

I. General information

NPI: 1730488024
Provider Name (Legal Business Name): KATHRYN A. RUSS ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4030 MOUNT CARMEL TOBASCO RD
CINCINNATI OH
45255-3400
US

IV. Provider business mailing address

5689 WAYSIDE AVE
CINCINNATI OH
45230-5131
US

V. Phone/Fax

Practice location:
  • Phone: 513-910-5124
  • Fax:
Mailing address:
  • Phone: 513-231-5043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC0007966
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC0007966
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: