Healthcare Provider Details

I. General information

NPI: 1003145152
Provider Name (Legal Business Name): JULIE RUSSELL PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5597 CEDAR BREAK DR
CENTREVILLE VA
20120-3329
US

IV. Provider business mailing address

443 CARLISLE DR STE A
HERNDON VA
20170-5623
US

V. Phone/Fax

Practice location:
  • Phone: 703-830-6315
  • Fax:
Mailing address:
  • Phone: 703-581-5875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number0015000440
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: