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General NPI Number Information
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NPI Number | 1427868181
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Entity Type | Individual
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Provider Name | ELLIE CLAIRE RUSSELL IMT4219
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Gender | Female
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Dates
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Enumeration Date | 01/13/2025
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Last Update Date | 01/13/2025
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Provider Practice Location Address
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Address Line | 715 N WASHINGTON BLVD
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City | SARASOTA
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State | FL
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Zip | 34236-4256
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Country | US
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Telephone | 941-876-8990
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Fax |
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Provider Business Mailing Address
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Address Line | 500 110TH AVE N APT 510
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City | ST PETERSBURG
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State | FL
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Zip | 33716-3153
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Country | US
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Telephone | 615-878-5775
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | IMT4219
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License Number State | FL
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