Healthcare Provider Details

I. General information

NPI: 1437635273
Provider Name (Legal Business Name): DORIS RENEE RUSSELL 27512 CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COMMERCIAL PL
NEWBURGH NY
12550-5306
US

IV. Provider business mailing address

3 COMMERCIAL PL
NEWBURGH NY
12550-5306
US

V. Phone/Fax

Practice location:
  • Phone: 845-220-2146
  • Fax: 845-220-2121
Mailing address:
  • Phone: 845-220-2146
  • Fax: 845-220-2121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number27512
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: