Healthcare Provider Details

I. General information

NPI: 1578743084
Provider Name (Legal Business Name): MS. RACHEL RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 05/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21520 PIONEER BLVD STE 110
HAWAIIAN GARDENS CA
90716-2604
US

IV. Provider business mailing address

21520 PIONEER BLVD STE 110
HAWAIIAN GARDENS CA
90716-2604
US

V. Phone/Fax

Practice location:
  • Phone: 562-865-3644
  • Fax: 562-865-3644
Mailing address:
  • Phone: 562-865-3644
  • Fax: 562-865-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number55348
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: