Provider Demographics
NPI:1447900873
Name:RUSSELL, CHEYENNE ROSE (OTR/L)
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:ROSE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 STATION PL
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-6578
Mailing Address - Country:US
Mailing Address - Phone:304-760-6300
Mailing Address - Fax:
Practice Address - Street 1:179 STATION PL
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-6578
Practice Address - Country:US
Practice Address - Phone:304-760-6300
Practice Address - Fax:304-201-5123
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2216225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics