Basic Information
| Provider Information | |||||||||
| NPI: | 1275171928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL- TARI | ||||||||
| FirstName: | HELEN | ||||||||
| MiddleName: | CLAIRE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSSELL | ||||||||
| OtherFirstName: | HELEN | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 107 TUTTLE RD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120933907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074350465 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 42084 STATE HIGHWAY 28 | ||||||||
| Address2: | |||||||||
| City: | MARGARETVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124552820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455862631 | ||||||||
| FaxNumber: | 8455861321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2019 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 002085-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 002085-1 | 01 | NY | NYS DEPARTMENT OF EDUCATION | OTHER |