Provider Demographics
NPI:1598531683
Name:RUSSELL, MARI
Entity type:Individual
Prefix:
First Name:MARI
Middle Name:
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 1:23511 CHAGRIN BLVD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5528
Mailing Address - Country:US
Mailing Address - Phone:216-856-2582
Mailing Address - Fax:
Practice Address - Street 1:23511 CHAGRIN BLVD APT 417
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5539
Practice Address - Country:US
Practice Address - Phone:216-507-1747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OH401390360512376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No376K00000XNursing Service Related ProvidersNurse's Aide