Healthcare Provider Details

I. General information

NPI: 1558128090
Provider Name (Legal Business Name): ELISE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 24TH AVE S
SEATTLE WA
98144-4637
US

IV. Provider business mailing address

2100 24TH AVE S
SEATTLE WA
98144-4637
US

V. Phone/Fax

Practice location:
  • Phone: 206-382-5340
  • Fax:
Mailing address:
  • Phone: 206-382-5340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: