Healthcare Provider Details

I. General information

NPI: 1770263733
Provider Name (Legal Business Name): BENTLEY REAGAN RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/19/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SPENRYN DR
MADISON AL
35758-1890
US

IV. Provider business mailing address

110 OAKLAND SPGS UNIT 6306
MADISON AL
35756-5583
US

V. Phone/Fax

Practice location:
  • Phone: 256-772-4400
  • Fax:
Mailing address:
  • Phone: 256-476-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBCBA1-26-2831150
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: