Healthcare Provider Details

I. General information

NPI: 1255465530
Provider Name (Legal Business Name): THERESA JOANNE RUSSELL CADC-11
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5494 PONY EXPRESS TRAIL
POLLOCK PINES CA
95726
US

IV. Provider business mailing address

2173 DANBURY WAY
RANCHO CORDOVA CA
95670-2271
US

V. Phone/Fax

Practice location:
  • Phone: 530-664-3758
  • Fax: 530-644-3782
Mailing address:
  • Phone: 916-635-6791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA8463203
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: