MEDICARE: TABBY JEANE RUSSELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1013213438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABBY JEANE RUSSELL

Provider Business Mailing Address
First Line	:	808 SILVER SAGE
Second Line	:
City	:	EVANSVILLE
State	:	WY
Zip	:	82636-9532
Country	:	US
Telephone Number	:	307-251-2459
Fax Number	:

Provider Business Practice Location Address
First Line	:	808 SILVER SAGE
Second Line	:
City	:	EVANSVILLE
State	:	WY
Zip	:	82636-9532
Country	:	US
Telephone Number	:	307-251-2459
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2011
Last Update Date	:	02/02/2011

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