MEDICARE: SARA ANNE RUSSELL LPC

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	101YM0800X	Mental Health Counselor	11159	AZ

General Provider Information

NPI Number	:	1033168927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA ANNE RUSSELL LPC

Provider Business Mailing Address
First Line	:	9156 E AVENIDA LAS NOCHES
Second Line	:
City	:	GOLD CANYON
State	:	AZ
Zip	:	85218-4675
Country	:	US
Telephone Number	:	480-983-9350
Fax Number	:

Provider Business Practice Location Address
First Line	:	5520 E MAIN ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-8793
Country	:	US
Telephone Number	:	480-969-2783
Fax Number	:	480-969-3521

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

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	07/08/2007

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