Healthcare Provider Details

I. General information

NPI: 1730927989
Provider Name (Legal Business Name): RETINA LYNN RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2024
Last Update Date: 03/14/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 HAZELTINE NATIONAL DR STE 106
ORLANDO FL
32822-5102
US

IV. Provider business mailing address

3200 HIAWASEE DR
ORLANDO FL
32835
US

V. Phone/Fax

Practice location:
  • Phone: 855-295-3276
  • Fax: 888-588-2752
Mailing address:
  • Phone: 407-286-4031
  • Fax: 888-588-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1730927989
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: