Provider Demographics
NPI:1861932485
Name:RUSSELL, AISHA (MS,LAT,ATC)
Entity type:Individual
Prefix:
First Name:AISHA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS,LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W NORTH AVE
Mailing Address - Street 2:PEC 131
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-3633
Mailing Address - Country:US
Mailing Address - Phone:410-951-3728
Mailing Address - Fax:410-951-6928
Practice Address - Street 1:2500 W NORTH AVE
Practice Address - Street 2:PEC 131
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-3633
Practice Address - Country:US
Practice Address - Phone:410-951-3728
Practice Address - Fax:410-951-6928
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00005512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer