Healthcare Provider Details

I. General information

NPI: 1306798046
Provider Name (Legal Business Name): BETHANY R. RUSSELL, PH.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44177 KELLY DR
BABCOCK RANCH FL
33982-5372
US

IV. Provider business mailing address

44177 KELLY DR
BABCOCK RANCH FL
33982-5372
US

V. Phone/Fax

Practice location:
  • Phone: 239-427-1635
  • Fax:
Mailing address:
  • Phone: 239-427-1635
  • Fax: 717-789-1914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. BETHANY R RUSSELL
Title or Position: CLINICAL DIRECTOR
Credential: PH.D., LMHC
Phone: 239-427-1635