Healthcare Provider Details

I. General information

NPI: 1538793856
Provider Name (Legal Business Name): TAMEKIO RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2072 SW SANDLEWOOD PL
GRESHAM OR
97080-9752
US

IV. Provider business mailing address

2072 SW SANDLEWOOD PL
GRESHAM OR
97080-9752
US

V. Phone/Fax

Practice location:
  • Phone: 503-702-6560
  • Fax:
Mailing address:
  • Phone: 503-702-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: