Healthcare Provider Details

I. General information

NPI: 1104648534
Provider Name (Legal Business Name): ERIC BERNARD RUSSELL ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15740 TURNBERRY ST
MORENO VALLEY CA
92555-4903
US

IV. Provider business mailing address

5870 ARLINGTON AVE
RIVERSIDE CA
92504-2037
US

V. Phone/Fax

Practice location:
  • Phone: 951-363-8449
  • Fax:
Mailing address:
  • Phone: 951-683-6596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number126347
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: