Provider Demographics
NPI:1144527219
Name:RUSSENBERGER, JANET M (OT)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:M
Last Name:RUSSENBERGER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:R
Other - Last Name:MCKINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:103 BOBBY REAPER RD
Mailing Address - Street 2:
Mailing Address - City:PANGBURN
Mailing Address - State:AR
Mailing Address - Zip Code:72121-9771
Mailing Address - Country:US
Mailing Address - Phone:501-728-4799
Mailing Address - Fax:
Practice Address - Street 1:7540 N 19TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7967
Practice Address - Country:US
Practice Address - Phone:188-887-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR934225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128094721Medicaid