Healthcare Provider Details

I. General information

NPI: 1750921938
Provider Name (Legal Business Name): CHRISTINA RUSSELL BS, MA STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N BROADWAY STE A
PERU IN
46970
US

IV. Provider business mailing address

1015 MICHIGAN AVE
LOGANSPORT IN
46947-1526
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 574-722-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: