MEDICARE: MR. RUSSELL VERNON PEARSON MSW

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	1041C0700X	Clinical Social Worker	LCSW-4155	AZ

General Provider Information

NPI Number	:	1225022148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RUSSELL VERNON PEARSON MSW

Provider Business Mailing Address
First Line	:	3717 E SHAPINSAY DR
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85242-5038
Country	:	US
Telephone Number	:	480-987-9460
Fax Number	:

Provider Business Practice Location Address
First Line	:	288 N IRONWOOD DR
Second Line	:
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85220-3830
Country	:	US
Telephone Number	:	480-982-2356
Fax Number	:	480-982-2449

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	07/08/2007

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