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General NPI Number Information
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NPI Number | 1356742605
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Entity Type | Individual
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Provider Name | MRS. DESIREE DAWN RUSSELL
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Gender | Female
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Dates
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Enumeration Date | 09/05/2014
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Last Update Date | 11/03/2015
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Provider Practice Location Address
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Address Line | 9 OVERLOOK RD
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City | QUINCY
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State | MA
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Zip | 02169-2315
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Country | US
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Telephone | 617-770-1795
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Fax |
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Provider Business Mailing Address
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Address Line | 500 VICTORY RD
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City | QUINCY
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State | MA
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Zip | 02171-3139
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Country | US
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Telephone | 617-745-2719
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | 3476
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License Number State | MA
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