Healthcare Provider Details

I. General information

NPI: 1225022148
Provider Name (Legal Business Name): RUSSELL VERNON PEARSON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 N IRONWOOD DR
APACHE JUNCTION AZ
85220-3830
US

IV. Provider business mailing address

3717 E SHAPINSAY DR
QUEEN CREEK AZ
85242-5038
US

V. Phone/Fax

Practice location:
  • Phone: 480-982-2356
  • Fax: 480-982-2449
Mailing address:
  • Phone: 480-987-9460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-4155
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: