MEDICARE: GEORGIA RENEE 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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1801226477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGIA RENEE RUSSELL

Provider Business Mailing Address
First Line	:	6767 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-9073
Country	:	US
Telephone Number	:	702-629-6340
Fax Number	:

Provider Business Practice Location Address
First Line	:	6767 W CHARLESTON BLVD STE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146
Country	:	US
Telephone Number	:	702-629-7928
Fax Number	:

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

Provider Enumeration Date	:	11/19/2013
Last Update Date	:	11/19/2013

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