Healthcare Provider Details

I. General information

NPI: 1003302613
Provider Name (Legal Business Name): MARSHA T RUSSELL CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4977 NORTHCUTT PL
DAYTON OH
45414-3839
US

IV. Provider business mailing address

4748 TENSHAW DR
DAYTON OH
45417-5930
US

V. Phone/Fax

Practice location:
  • Phone: 937-387-6395
  • Fax:
Mailing address:
  • Phone: 937-266-5702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.173387
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: