MEDICARE: DEREK RUSSELL

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1699291971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK RUSSELL

Provider Business Mailing Address
First Line	:	8289 DOUBLE POPLARS LN
Second Line	:
City	:	WARRENTON
State	:	VA
Zip	:	20187-8313
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 EISENHOWER AVE STE 604
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-4688
Country	:	US
Telephone Number	:	703-684-0334
Fax Number	:

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

Provider Enumeration Date	:	08/17/2017
Last Update Date	:	08/17/2017

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