Healthcare Provider Details

I. General information

NPI: 1326636614
Provider Name (Legal Business Name): ZSANEE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ZSNWHE MATTEUCCI

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 GUILFORD AVE
HAGERSTOWN MD
21740-6349
US

IV. Provider business mailing address

649 GUILFORD AVE
HAGERSTOWN MD
21740-6349
US

V. Phone/Fax

Practice location:
  • Phone: 124-065-1943
  • Fax: 855-579-6758
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: