Healthcare Provider Details

I. General information

NPI: 1811458813
Provider Name (Legal Business Name): KARA ELIZABETH RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2019
Last Update Date: 03/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 BLUFFS AVE
BOWIE TX
76230-8571
US

IV. Provider business mailing address

982 BLUFFS AVE
BOWIE TX
76230-8571
US

V. Phone/Fax

Practice location:
  • Phone: 940-577-4550
  • Fax:
Mailing address:
  • Phone: 940-577-4550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number35332
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: