Provider Demographics
NPI:1033954441
Name:DERUSSY, SEAN MICHAEL (PTA)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:MICHAEL
Last Name:DERUSSY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 EASTWOOD DR APT 10311
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-4414
Mailing Address - Country:US
Mailing Address - Phone:513-405-1051
Mailing Address - Fax:
Practice Address - Street 1:1198 SMILEY AVE STE F
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-1866
Practice Address - Country:US
Practice Address - Phone:513-671-6362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA013768225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant