Healthcare Provider Details

I. General information

NPI: 1770739229
Provider Name (Legal Business Name): MS. PEGGY L RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SHIELDS AVE
FRESNO CA
93726-7029
US

IV. Provider business mailing address

3707 E SHIELDS AVE
FRESNO CA
93726-7029
US

V. Phone/Fax

Practice location:
  • Phone: 559-229-9040
  • Fax: 559-229-9060
Mailing address:
  • Phone: 559-229-9040
  • Fax: 559-229-9060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC6191214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: