Healthcare Provider Details

I. General information

NPI: 1154246106
Provider Name (Legal Business Name): RONALD RUSSELL II QBHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 BROADWAY ST
LITTLE ROCK AR
72206-1222
US

IV. Provider business mailing address

1817 BROADWAY ST
LITTLE ROCK AR
72206-1222
US

V. Phone/Fax

Practice location:
  • Phone: 501-551-1201
  • Fax: 501-615-8721
Mailing address:
  • Phone: 501-551-1201
  • Fax: 501-615-8721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: