MEDICARE: RUSSELL PRAUSE MS, LPC-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	20565	AZ
2	101YM0800X	Mental Health Counselor	P2501015	AR
3	101YM0800X	Mental Health Counselor	LPC-20565	AZ

General Provider Information

NPI Number	:	1417560806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL PRAUSE MS, LPC-S

Provider Business Mailing Address
First Line	:	701 NW MCNELLY RD STE 9
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72712-9160
Country	:	US
Telephone Number	:	623-888-4310
Fax Number	:

Provider Business Practice Location Address
First Line	:	14800 W MOUNTAIN VIEW BLVD STE 210
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85374-2703
Country	:	US
Telephone Number	:	623-888-4310
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2020
Last Update Date	:	01/20/2026

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