Provider Demographics
NPI:1902594492
Name:RUSSELL, SAMANTHA JORDAN
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JORDAN
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 1:1332 PRAYVIEW CT
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-8721
Mailing Address - Country:US
Mailing Address - Phone:513-649-5445
Mailing Address - Fax:
Practice Address - Street 1:4320 BRIDGETOWN RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-4428
Practice Address - Country:US
Practice Address - Phone:513-574-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH010471225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant