Provider Demographics
NPI:1750362448
Name:RUSSELL, KATHLEEN MARIE
Entity type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4231
Mailing Address - Country:US
Mailing Address - Phone:419-479-5960
Mailing Address - Fax:
Practice Address - Street 1:4235 SECOR RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4231
Practice Address - Country:US
Practice Address - Phone:419-479-5960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-9942225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2375111Medicaid
OHH188771Medicare PIN
OH4097953Medicare ID - Type Unspecified
OH4097955Medicare ID - Type Unspecified
OH344329OtherANTHEM BCBS
MI4745813Medicaid
OH4097957Medicare ID - Type Unspecified
MI4745985Medicaid
OH2375111Medicaid