Healthcare Provider Details

I. General information

NPI: 1437026358
Provider Name (Legal Business Name): TIFFANY T RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2025
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 DRY FORK RD
DRY FORK VA
24549-4139
US

IV. Provider business mailing address

6245 DRY FORK RD
DRY FORK VA
24549-4139
US

V. Phone/Fax

Practice location:
  • Phone: 434-710-0831
  • Fax:
Mailing address:
  • Phone: 434-710-0831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number11862
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: