Healthcare Provider Details

I. General information

NPI: 1932950722
Provider Name (Legal Business Name): VICTORIA N RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2024
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E GAMBIER ST
MOUNT VERNON OH
43050-3510
US

IV. Provider business mailing address

106 E GAMBIER ST
MOUNT VERNON OH
43050-3510
US

V. Phone/Fax

Practice location:
  • Phone: 740-397-2660
  • Fax: 740-392-3613
Mailing address:
  • Phone: 740-397-2660
  • Fax: 740-392-3613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS2613588
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: