Healthcare Provider Details

I. General information

NPI: 1295017671
Provider Name (Legal Business Name): ELIZABETH C RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 BEAR CORBITT RD
BEAR DE
19701-1323
US

IV. Provider business mailing address

925 BEAR CORBITT RD
BEAR DE
19701-1323
US

V. Phone/Fax

Practice location:
  • Phone: 302-454-2400
  • Fax:
Mailing address:
  • Phone: 302-454-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number59349
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: